The right and wrong of Right to Health
Why do doctors oppose such Acts? Why would they not support the global move towards standardising care? And the right to affordable healthcare? India has one of the world’s maximally privatised healthcare system. But there is something even more unique about this model. Doctors invest in hospitals (StockPic)
How do we define an emergency? Why does the government not do its job? Why should private hospitals treat emergencies? Who will pay? Who will take responsibility to transfer patients? What if people demand emergency treatment
Sanjay Nagral
April 10, 2023, Hindustan Times
Strap: Medical associations are largely led by hospital owners. The conflict of interest is stark. The entanglement severe. Hence, attempts to push doctors to accept patients not on their terms or control face resistance
Why do doctors oppose such Acts? Why would they not support the global move towards standardising care? And the right to affordable healthcare? India has one of the world’s maximally privatised healthcare system. But there is something even more unique about this model. Doctors invest in hospitals (StockPic)
In 2014, the Maharashtra Government set up a committee with a mandate to formulate a state version of a Central Act called the ‘Clinical Establishment Act’. This act governs all healthcare institutions in India and sets standards. The then health minister and secretary were keen on a more comprehensive act than the central one. Among the tasks given to the committee was an interesting one. “To rationalise fee structure across healthcare institutions”. The committee had diverse representation. State government officials, professional medical organisations and representatives of NGOs working in public health and patient’s rights. I was a nominated member. One of my rare trysts with the corridors of
Mantralaya. It was an educative experience. On how government committees function and how policies are formed, the interests at work. But the biggest insight had nothing to do with government or bureaucracy.
The Clinical Establishment Act highlights emergency care and the issue came up in the very first meeting. As a surgeon, I pointed to the chaotic state of emergency care especially for accident victims and suggested that it was an opportunity for the state to setup an organised trauma care system. I presented a plan for hospitals with a certain capacity to be identified as emergency care centres and in turn link it to large hospitals and the ambulance system through a centralised control room with access to information on beds. I also proposed that all hospital staff should be compulsorily trained in Basic and Advanced Life support as is the case in most countries. The government was interested. But some of the committee members were not.
How do we define an emergency? Why does the government not do its job? Why should private hospitals treat emergencies? Who will pay? Who will take responsibility to transfer patients? What if people demand emergency treatment? Does the government have a right to force private hospitals to treat? Don’t doctors have a right to decide whom they want to treat and whom they don’t? The doctors representing the medical organisations in the committee kept raising these questions. Most of them were hospital owners.
Then came the issue of rationalisation of fees. Some of us suggested that we propose grading of fees and a range depending on the facility and geographical location. This created pandemonium. How can governments decide fees? Is it Constitutional? We were accused of creating conditions for closure of nursing homes. And serving the interests of large corporate hospitals. The IMA launched a campaign through WhatsApp calling for opposition to the committee. Several batchmates called me to say “Why are you doing this?” “Why are you against the medical profession?”
Finally, a watered-down version was presented to the health minister. Some of us presented a dissenting note. The government changed. The Act was shelved. Everybody lived happily thereafter. Almost. Till Covid. When Rajesh Tope, the health minister, lamented, “If we had a comprehensive Clinical Establishment Act we need not have invoked special Acts like the Epidemic Act.”
Why do doctors oppose such Acts? Why would they not support the global move towards standardising care? And the right to affordable healthcare? India has one of the world’s maximally privatised healthcare system. But there is something even more unique about this model. Doctors invest in hospitals. They own them. Their income is directly dependent on the hospital’s earnings. They are used to patients paying immediately out of pocket. The idea that healthcare costs are moving towards third party payment has still not sunk in.
Medical associations are largely led by hospital owners. The conflict of interest is stark. The entanglement severe. Hence, attempts to push doctors to accept patients not on their terms or control face resistance. Governments are in a Catch 22 situation of their own making. More and more political parties are realising that healthcare issues are beginning to gain electoral traction. But years of underfunded and neglected public health and an enormously dominant and developed private sector means that to improve access they necessarily have to involve the private sector. So, when Rajasthan decided to implement a Right to Health act there was a huge opposition from organisations like the IMA who mainly represent small hospital owners.But the final straw which provoked the massive pushback on the Rajasthan Bill, which saw the intriguing support of even government doctors, was perhaps the term “Right” in the bill. Doctors’ WhatsApp groups were abuzz with attacks on the idea of how the idea of ‘right’ to health can be misused. That term sounds alien and is also pregnant with the possibility of empowerment of patients. It’s very different from the largesse or favour mode that healthcare currently revels in. That’s why it causes so much discomfort. But a right to life is a framework which our Constitution espouses. We have all applauded the right to information and right to education initiatives. Why not then in a matter of life and death?
Many of us are somewhat insulated from the challenge of access to care even during an emergency. With money and a large private sector at our beck and call we are reasonably well served though Covid did test the tenuous nature of this security. But many citizens have no such choice.
Access to decent healthcare being dependent on out-of-pocket payments is not a sign of a caring society. Whilst medical professionals may be uncomfortable with the idea of controlled third-party payment we have to move towards this as an enlightened collective ideal. Otherwise, the enormous advances of modern healthcare will remain the preserve of a select few. Many nations have moved towards universal healthcare. We cannot remain in the dark ages in this area.