Patralekha Chatterjee | Right to health in India: Raj law to be test case?

In a country where nearly half of all healthcare costs are still paid for by the patients themselves, you would think a law guaranteeing people’s right to health would be welcomed universally, and with open arms. But in India, you never can tell.

In Rajasthan, which recently became the first state in the country to introduce a law that makes access to healthcare a legal entitlement of every resident of the state, thousands of doctors in Jaipur have been demonstrating against the law as part of a nationwide stir called by the Indian Medical Association (IMA). The IMA represents around 3.5 lakh doctors in the country. The high-pitched verbal jousts continue on the streets and in the social media, with many private doctors making their displeasure about the landmark legislation loud and clear.

As I write, comes the news that medical services in Rajasthan are likely to be seriously affected with government doctors and faculty members at medical colleges announcing a one-day mass leave in solidarity with the private doctors agitating against the new law. Emergency services, however, will be exempted, says a PTI report. The ongoing agitation has already affected patient care.

Rajasthan chief minister Ashok Gehlot says his government is ready to listen to doctors. It is tough to predict what lies ahead.

An ordinary citizen with vivid memories of the Covid-19 pandemic at its terrifying peak is likely to be flummoxed. Healthcare costs left tens of thousands of families financially crippled or crushed. Everyone in this country, barring the super-rich, lives in constant fear of a medical emergency in the family. Everyone knows that even if you have adequate insurance, all costs are not covered. This means using up one’s savings to pay for treatment and heart-breaking choices.

The new law brought in by the Ashok Gehlot government in Rajasthan is an attempt to deal with such fears.

In brief, under the new law, every resident in the state has the right to avail free of cost treatment without prepayment at any health institution in the state. This includes emergency treatment. No government or private hospital or doctor can refuse a person seeking emergency treatment. There are penalties if they do.

Rajasthan’s protesting doctors, many of whom have stopped work, say the new law is unconstitutional, unacceptable and that the state government is trying to shift its own responsibility (of providing healthcare to citizens) to private doctors. They fear they will not be reimbursed adequately, or in time, and will be punished for circumstances beyond their control.

They want the Gehlot government to take back the law before they agree to have any discussions.

Parsing through the arguments and counter-arguments swirling around, one thing is glaringly evident -- there is a complete breakdown of trust between the feuding parties. This has led to many people assuming worst-case scenarios and making the worst-possible assumptions about those they do not agree with. This has ramifications beyond the law, and beyond Rajasthan. Without trust, there can be no meaningful dialogue nor movement forward. That helps no one.

It is imperative, therefore, to differentiate between abuse masquerading as argument and legitimate concerns and constructive suggestions. In a hyper-polarised political milieu, and with the Assembly and Parliament elections not too far away, we must also recognise the dangers of letting polarisation seep into a discussion about healthcare in India.

Many protesting doctors say they have no quarrel with the right to health. Their problem is with Rajasthan’s right to health law, which they see as transferring what is essentially a state responsibility to private doctors. How valid are the fears? Or prejudice.

Are all doctors who are protesting greedy, thoughtless, and uncaring people who have no compassion for ordinary patients? The answer is “no”. But malpractices do take place and this does have an impact on public trust in the healthcare industry. Is the new law going to extract “free” services from private doctors in case of an emergency in the public interest? The answer is “no”. Read the text of the new law. It has specific sections on “accidental emergency” as well as reimbursement.

Many doctors say the law does not make clear when, and how much, will be reimbursed. This is a genuine concern and must be clarified in the implementation guidelines. Hopefully, this will be published soon. The doctors say their worry is also about the punitive clauses in the law and about being scapegoated in circumstances beyond their control. Some doctors paint an apocalyptic image of an overstretched health system collapsing if the new law is implemented. Others have asked for a phased implementation, starting with a taluka or a district.

But the answer to all these fears is not trashing a law that seeks to ensure that no one dies or remains untreated simply because of the inability to pay.

Civil society activists say the public overwhelmingly supports the new legislation and that the fears of the protesting doctors are misplaced. Chhaya Pachauli, an activist with the Jan Swasthya Abhiyan (People's Health Movement-India), says many of the issues being raised by the protesting doctors have been dealt with in the law that was recently passed in the Rajasthan Assembly.

A lot of misinformation is swirling around and many who are protesting today are going by earlier versions of the law, says Ms Pachauli. She points out that the law had been referred to a select committee, that many modifications were made to earlier versions, and that under the new statute, the role of the private sector is mainly for emergency care treatment. This is necessary, she says, because in case of accidents, a patient must be rushed to the nearest health centre or hospital, government or private.

Mohan Rao, former professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, is of the view that there should be no public subsidy to the private sector. Instead, the public health sector should be substantially revamped, both in terms of human resources and technology. He cites the example of Tamil Nadu, where posting full-time nurses in the primary health centres led to an increase in the number of deliveries in PHCs and a dip in deliveries in private clinics and hospitals.

The bottom line: Rajasthan’s right to health law is potentially a radical step in the public interest in the country. But implementation guidelines and enforcement are the key to achieving its stated goals. They must take on board all genuine concerns. They must also be backed by adequate financial resources. Without this, the law would land up confirming the worst-case scenarios imagined by its detractors.