While a perfect RTH/UHC Bill might be a Utopia, all stakeholders should learn from Rajasthan’s experience
The signing of an MoU between the Rajasthan government, Indian Medical Association- Rajasthan, Private Hospital and Nursing Home Society (PHNHS) and United Private Clinics and Hospitals of Rajasthan (UPCHAR) takes the state one step closer to launching a Right to Health (RTH) Bill.
Or does it?
Once the eight-point MoU is applied, only 47 out of the state’s 4100 private health facilities remain part of the Bill. Eleven of these 47 health facilities are private medical colleges, while 36 got land at concessional rates, two of the inclusion criteria of the MoU.
So, will citizens in Rajasthan be able to actually exercise their right to healthcare, if such a large proportion of private health facilities are not covered by the Act? Is the state confident that public health facilities will meet the demand and aspirations of their citizens for good quality healthcare?
And will this become the template RTH Bill and modus operandi followed by other state governments and hospital/doctor associations? If yes, is Universal Healthcare (UHC) in India destined to remain a distant, or worse, a dysfunctional dream in India?
Doctors in the state from the private sector had launched protests after the Bill was introduced on March 21, hampering access to healthcare. Most, but not all, are expected to resume duty after the MoU. For now, the MoU resolves the stalemate and leaves the door open for more consultation between the government and representatives of the private healthcare sector, to find common ground.
What’s the legal status so far? The RTH Bill was introduced and passed by both the houses of Rajasthan legislature unanimously. It is only after the Governor gives assent that the “Bill” will become an “Act”. The governor has not given assent to this Bill.
Thus, it remains to be seen if these recommendations will be incorporated at the Bill stage, rather than as amendments after it becomes an Act. The former process will reduce chances of these amendments being challenged and overruled during the implementation process.
There is no doubt that Rajasthan’s RTH Bill is a step in the right direction, even though the motivation and application appear to be flawed. With other state governments (especially those due for elections this year) in a wait-and-watch mode, it is imperative that all stakeholders re-examine the issues carefully and resolve them, in the true spirit of giving citizens a right to healthcare and building the infrastructure for a sustainable and equitable UHC system.
Legal experts are of the opinion that Rajasthan’s RTH Bill, in its original form, was harsh on doctors, in the sense that they will not only have to admit and take care of an emergency patient without any payment but may also have to incur the additional cost of transporting the patient to another hospital. The Bill stated that this cost will be reimbursed, but there is no clarity on the amounts and timeline to reimbursement. There have been numerous well reported accounts of the frustrating experience of doctors and hospitals in other states, where similar schemes are in force (not as a right to health).
Post the MoU, the legal experts surmise that the main issue seems to have been resolved, as smaller hospitals who were at the forefront in opposing this Bill, have now been exempted from the provisions of this Bill. This would seem a logical exclusion, as most smaller hospitals and standalone clinics may not have the clinical specialists and hospital infrastructure to deal with all emergencies. Neither do they have the financial reserves to wait for reimbursements from the government for treatment administered under such schemes.
Associations representing hospitals from the private sector, the Association of Healthcare Providers (India) (AHPI) and NATHEALTH, as well as private practitioners belonging to the Alliance of Doctors for Ethical Healthcare (ADEH), were wary of the many grey areas. While Dr Girdhar Gyani, Director General, AHPI welcomes the agreement, he points out that the hospitals which come under points 3.c and 3.d in the MoU (3.c refers to hospitals built on land acquired free or at concessional rates from the government, whereas 3.d refers to hospitals run by trusts) which remain covered by the Bill, will have to bear the full patient load as they provide the bulk of tertiary care and critical patients will find their way to such hospitals.
These hospitals contend that there is no clarity about the mode of payment and more importantly, about the rate at which reimbursement will be made for critical care procedures. AHPI’s statement emphasises that this has been a perennial problem, even with present government schemes like Rajasthan’s Chiranjeevi scheme, the difference being that participation in such schemes is optional but once the RTH Bill comes into play, it will become mandatory.
Stressing that AHPI also supports the concept of RTH, as long as it takes care of the financial sustainability of hospitals, the statement warns that financial sustainability will be a serious issue, impacting the survivability (of the hospitals) in the long run. The statement indicates that AHPI and IMA will work together to take up these issues with the government under the 8-point agreement.
If hospitals are worried about the financial implications of the RTH Bill, then doctors are concerned about being the target of violence by patients and their caregivers, as well as being sued for malpractice. While the ADEH welcomed the spirit in which the Rajasthan Government has brought the RTH Bill, it appealed (in a pre-MoU statement) to authorities to address the core issues which are nurturing the “deep unrest amongst private healthcare practitioners.” On the financial side, ADEH hoped the state will also make the necessary budgetary allotment and back the bill with robust political will.
The ADEH had recommended that the Bill should also specify the nature of primary emergency treatment and requested that the clause which reserves the right of the government to add more emergencies as and when needed; should be nuanced by the addition of the phrase – ‘after consulting doctors’ organisations. Lastly, the ADEH had suggested a robust accountability mechanism in the rules whereby along with doctors, the government officials would also be made accountable, as a robust grievance redressal system for both patients and doctors is necessary for success.
The NATHEALTH statement before the MoU was signed, points out that UHC has never been achieved anywhere in the world “where the private sector fears that public good will be delivered at private cost”. Dr Ashutosh Raghuvanshi, President, NATHEALTH had therefore requested the Rajasthan Government to put this Bill on abeyance till a consensus is achieved and an operational framework is established.
While a perfect RTH Bill/Act might be a Utopia, Rajasthan’s experience has many learnings. The reactions and recommendations from associations show that any RTH regulation needs to balance the interests of healthcare users (patients) and providers (hospitals, both private and government). And it will need a consultative, transparent approach, a meeting of minds or at least finding common ground, to start the process and put a framework in place.