Indian state passes historic ‘right to health’ law. So why are doctors unhappy?

Doctors in Rajasthan have hit the streets in protest after the state became the first in the country to pass legislation guaranteeing the “right to health”, claiming it will put an unsustainable burden on private healthcare providers.

Private sector doctors have been protesting for more than 10 days across the state after the Right to Health Act was passed in the state assembly last month, demanding a rollback of the law that makes access to healthcare a legal entitlement for every citizen of the state.

The Rajasthan government also provides health insurance coverage of 2.5m rupees (approx £25,000) per annum for a family that covers more than 1,500 procedures, as well as free diagnostic tests at government centres, under welfare schemes.

Dr Abhay Shukla, national co-convenor of the Jan Swasthya Abhiyan network of non-profits working in the healthcare sector in India, described the new law as “a major step forward”.

“This is the first time a state government has laid down in a comprehensive way the right to healthcare,” he said to The Independent.

However, protests have continued against the Congress’s Ashok Gehlot-led state government and, in a massive show of strength on Monday, thousands of doctors took to the streets in the capital Jaipur pressing for their demands.

On Wednesday, medical services were crippled in the northern state as government doctors joined the agitation against the law in a one-day strike, reported the Press Trust of India. Emergency services were, however, exempted from the strike.

Speaking to The Independent, Dr Amit Yadav, former president of the Jaipur Association of Resident Doctors, explained their opposition to the new law. “This law has many provisions that are not in favour of both doctors and patients. It only seeks to hamper the relationship between the doctors and patients and puts a financial burden on doctors.

“Private doctors, resident doctors are all protesting and will continue to protest till our demands are met.”

The Indian Medical Association (IMA), the country’s largest association of medical workers, has also announced its support for the protests. On Tuesday, the body called for a “Black Day” to be observed by all members in solidarity with the protesting doctors in Rajasthan and urged the state government to engage in dialogue.

The law passed on 21 March by the state assembly gives every Rajasthan resident the right “to avail free OPD (outpatient department) services, IPD (inpatient department) services, consultation, drugs, diagnostics, emergency transport, procedure, and emergency care as provided by all public health institutions accordantly to their level of healthcare”.

The legislation was first introduced in the state assembly in September but was sent to a select committee. It was subsequently amended after the select committee’s report.

The law also says that all citizens in the state will have the right to emergency treatment and care “without prepayment of requisite fee or charges” at any healthcare facility, including private providers. It is this clause regarding emergency healthcare services without any prepayment that has become the main bone of contention between the state government and the doctors.

The law describes an “emergency” as “accidental emergency, emergency due to snake bite/animal bite and any other emergency decided by State Health Authority under prescribed emergency circumstances”.

Dr Sharad Kumar Agarwal, president of the IMA, said that the law is “draconian” and puts the onus on private doctors to fulfill the government’s welfare responsibilities. “This is a bill brought as a populist measure by the government because the elections are around the corner.”

The state is slated to go to the polls this year. After objections from doctors, the law passed by the assembly featured several changes including defining an emergency as well as the healthcare institutions that are required to provide such services without any prepayment.

The earlier version of the law stated that such emergency treatment and care will be provided by “any health care provider, establishment or facility, including private provider, establishment or facility”, but the amended law states that such services will be provided by “public health institution, health care establishment and designated health care centres, qualified to provide such care or treatment accordantly to their level of health care, promptly as prescribed or as per guidelines.”

Dr Yadav said that if the emergencies included only the three defined ones, doctors would not be agitating. “If it is only these three emergencies then there is no problem – but this is still the ‘emergency defined by state health authorities’, which is not at all clear,” he says.

Dr Agarwal added that despite the changes and the definition of emergency stated in the law, there remains ambiguity. “For a patient, even a simple headache is an emergency but for doctors things that endanger life is an emergency.

“What if a cardiac arrest patient goes to an ophthalmologist? The public won’t know the difference because the government is publicising that you can go to any doctor and then that doctor will refer you to another doctor (if need be). There will be loss of time and there can be loss of life.

“The government is saying that the doctors will have to pay for transportation for such patients (in case of such emergency referrals). But how will this happen? Not every doctor has an ambulance.”

According to the law, if patients do not pay the requisite charges after being provided proper emergency care, stabilisation and transfer, “the healthcare provider shall be entitled to receive requisite fee and charges or proper reimbursement from state government in prescribed manner as the case may be.”

Dr Agarwal says that the government is silent on the transportation fee that will be incurred by private doctors. “If the patient doesn’t pay, who will pay?”

Doctors say that the process of reimbursement is also not clear. “They are saying that it will be reimbursed but how will this be done is not mentioned anywhere,” said Dr Yadav.

Public health experts, however, say that while some ambiguity has been left in the law, it is an important step to standardise delivery of public healthcare across the state.

“The kind of opposition we are seeing from the private sector is surprising because 95 per cent of the bill relates to the public sector,” says Dr Shukla, who was also one of the people involved in the initial stages of drafting the bill. “The only section that concerns the private sector is the emergency provisions.

“Due to the repeated modifications requested by the private sector and in order to address their concerns, some sections in this regard have been drafted in a hurry that leaves some scope of ambiguity.”

According to Dr Shukla, even in the case of the emergency provision, it is clearly stated that the government will provide reimbursement. “The law also clearly mentions designated facilities will be required to provide care as per their level of qualification. So it is not that an ophthalmic hospital will be asked to give cardiac care.”

He added that if private doctors have an issue with these sections, they can be confirmed once the rules of the act are notified. “This can be clarified in the rules and guidelines in a manner in which there is no inappropriate expectation from private hospitals to provide emergency care which is beyond their capacity. And those who have issues can make them known at that stage. But what is happening now is making a mountain out of molehill,” he said.

Amid the ongoing protests, the Rajasthan government has said that the legislation will not be withdrawn “at any cost”.

“If there is any problem with the bill, then we are ready to hold a discussion but the bill won’t be taken back. At any cost, we will not take back the bill,” state health minister Prasadi Lal Meena said to news agency ANI.

“After a lot of discussions, the Right to Health bill was brought by our government. People of the state are benefiting from it. We held discussions and abided by all demands of protesting doctors. CM has appealed to them to come back to work. They are taking undue advantage,” he added.

Although protests have continued, doctors say that they are ready to hold discussions if the government invites them for talks. “We don’t want to sit on the roads and protest,” says Dr Agarwal. “Call the doctors, talk to them. Why is the government hesitant in doing so? If there is any further consultation invitation we will go,” he said.

Despite the stalemate, experts say that the law places an obligation on the state to provide a certain level of standardised public healthcare to mariginalised areas.

“Area-wise, Rajasthan is the largest Indian state with many desert and sub-rural areas where healthcare delivery is not optimal,” said Dr Shukla. “The main positive impact will be that geographically and otherwise marginalised groups who may not have been receiving adequate care will now be able to do so.”

The law also includes the creation of district health authorities and a state health authority, which can inspect hospitals and clinics, and act as grievance redressal systems in case of complaints. These authorities will also formulate guidelines to implement the law and advise the government on treatment protocol.

“In a way, the state is placing upon itself a certain obligation that a certain level of public health services will be delivered across the state, so this is definitely a very positive provision,” said Dr Shukla.