The Rajasthan Right to Health (RTH) Bill, which became an Act in April, had caused a bitter row following which the State government agreed on some exclusions. Many doctors termed the Act draconian, while public health activists have largely stood by it. But there are certain aspects of the Act that have attracted little discussion, which also make it unfit to be an ideal precedent for other States.
Iterations, before and after
Comparing the two iterations of the RTH Bill, one before and another after the select committee review, is a good starting point for a review. The primary iteration was sent for the select committee’s review in 2022, and the amended Bill was passed on March 21, 2023, which stoked protests. Even a cursory review brings out how the amended version, which sparked the row, was itself a highly moderated version attuned strongly to the interests of the medical community.
Following the select committee amendments, some definitions (accidental emergency, emergency care, and first aid), were added to the Bill. In addition, the term ‘designated health care centres’ was introduced, and a reimbursement clause for unpaid emergency care was added. These additions are commendable. However, most other changes in the amended Bill were not so salutary at least as far as protecting public health interests is concerned.
This shows, foremost, in the renewed composition of the State and district health authorities. For the State health authority, the initial iteration included three representatives, from ayurveda, homoeopathy, and unani, as ex-officio members. Instead, the amended Bill had provision for only one representative from the alternative medical systems, with medical education representatives filling for the remaining two. What is even more striking is that the amended Bill swapped public health/hospital management experts with Indian Medical Association (IMA) representatives as nominated members. This leaves these authorities with little or no representation from the public health fraternity and, most importantly, from the community for which the Act is aimed.
Further, the powers of the administration organs were significantly circumscribed in the amended Bill. The grievance redress system proposed in the initial iteration was also significantly overhauled in the amended Bill. Initially proposed to be handled through web portals, helpline centres, and officers concerned within 24 hours, patient grievances will now be handled by the very health-care institution in question within three days. This introduces conspicuous conflicts of interest. That apart, it stands to compound the administrative burden of hospitals. This predisposes patient grievances to being sloppily or perfunctorily handled, and more often than not, being settled informally.
Health legislation embraces not just curative medical care but also health promotion, disease prevention, and important social determinants such as nutrition, which have a stronger bearing on health than medical care. The current RTH Act lacking in public health representation is ill positioned to achieve these ends or to serve as a template for other States or a pan-India legislation. Coming now to the memorandum of understanding which made the Bill somewhat palatable for doctor associations. The State government has assured that private multispecialty hospitals with less than 50 beds, and those that have not availed of concessions or subsidised land/buildings from the government, will be kept out of the ambit of the law, even if temporarily. It effectively excludes the plethora of small and medium hospitals which predominate in the health-care landscape, particularly outside the urban agglomerations. Contrast this with the The Emergency Medical Treatment and Labor Act (EMTALA) — the U.S. legislation ensuring public access to emergency care — which covers 98% of hospitals.
The prognosis
Despite being a moderate Bill, some of the objections calling for an in-toto repeal have been rather frivolous, for instance, over the ambiguous definitions of some terms such as ‘emergency’. Medical-legal definitions are perennially given to ambiguities, and even widely accepted definitions are typically imprecise and replete with ambiguities. It only behoves all parties in such cases to work together to arrive at the best elaboration, rather than demanding an outright repeal of a Bill with far-reaching implications for public health beyond just emergency care. Again, the EMTALA example shows that some residual ambiguities are irredeemable and are routinely navigated using risk-benefit and reasonable confidence principles.
The foremost lesson for the state is that such legal pronouncements should be meticulously drafted to pre-empt opposition from arising in the first place. Second, for any true health legislation to arise, the government has to keep away from being swayed by organised medical interests alone. The common subtext of most medical protests has been that private medical practice should be as laissez-faire as possible, which is incompatible with equitable, universal health care. Governments and the medical community should sensitise themselves to the broader social dimensions of health and health legislation. Last, but not the least, governments should realise that getting onto such radical pieces of legislation without threshold levels of enough financial preparedness can backfire, as it is the state’s obligation to provide health care, and not that of health-care providers by disregarding their own livelihood.
Dr. Soham D. Bhaduri, a health policy and leadership specialist, is chief editor of ‘The Indian Practitioner’
