Right to health bill: Putting healthcare on the road to recovery

A Primary Health Centre (PHC) in Goa offers dialysis, breast cancer screening, in-patient service, heart attack emergency management and trauma care, all under one roof. Too good to be true? At the 15-bed Pilliem Dharbandoda PHC in South Goa, all this and more is available to residents and non-residents within a 60 km radius. Could this rarity soon be the norm?

The Right to Health Act approved last month by the Rajasthan assembly makes it a legal obligation for the state to provide such facilities free of cost to residents of the state. Once enacted, the Act, it is estimated, will have a recurring annual expenditure of Rs 14.5 crore.

The advocacy group Prayas points out that Clause 4 of the Bill shifts the onus of delivering medical services to the government. The government is ‘obligated’ to provide funds, set up institutions, constitute grievance redressal systems, and take the initiative to set up a state health authority and district health authorities. Beyond resolving complaints, the authorities would be tasked with planning and monitoring healthcare services, and conducting routine clinical, social and economic audits.

An earlier draft of the law had also covered visitors, non-residents and migrant workers. That clause, however, appears to have been dropped from the Bill finally approved. There have been other dilutions under duress. Doctors and private hospitals in Rajasthan resorted to a two-week work strike and took out huge processions in Jaipur in protest.

An agreement eventually signed on April 4 excused hospitals and nursing homes built on ‘private land’ from the ambit of the Act. Some doctors describe this as a ‘self-goal’ of healthcare providers (HCPs) because while the state government will be under no obligation to reimburse the cost of emergency care offered by these medical centres, they will still be bound to offer their services to patients.

Ironically, the government had already undertaken to leave out small hospitals with fewer than 50 beds. The Association of Healthcare Providers of India claims that small hospitals with 11 to 50 beds comprise 65 per cent of the private hospitals in the country and those with fewer than 10 beds make up for 14 per cent. With almost 80 per cent of the private hospitals thus left out of the net, the primary burden of offering emergency healthcare will have to be shouldered by government hospitals and medical colleges, private medical colleges and hospitals receiving aid from the government and hospitals run by trusts.

Medical ethics do bind all doctors and hospitals to offer emergency medical care to patients. The Right to Health Act passed by the Rajasthan assembly in March has now made it legally binding. For the first time in the country, the law makes it obligatory for the state to bear the cost if a patient is unable to pay.

This pioneering and pathbreaking law comes in the wake of the Chiranjeevi Yojana that offers medical insurance up to Rs 25 lakh per family and accident insurance up to Rs 10 lakh. This is in addition to the Union government’s Ayushman Bharat Yojana which offers insurance up to Rs 5 lakh for each family.

Apart from the right to emergency care, the Act gives every person the right to free healthcare at all public hospitals, prohibits discrimination based on illnesses and other conditions, gives patients the right to access their medical records if they want a second opinion, obligates hospitals to provide itemised bills and establish a grievance redressal body for patients.

Several states make lifesaving emergency care a precondition for granting licences to clinical establishments. The Right to Health Bill adds a buffer by granting establishments the right to recover expenses from the state.

The ‘out of pocket’ expenses of households account for an estimated 75 per cent of current healthcare expenditure. Every year, 63 million Indians slide into categorisable poverty due to such expenses, a fact even admitted in the health policy of 2017. Our public health spending is among the lowest in the world at 1.1 per cent of GDP against the minimum 5 per cent recommended by the WHO.

The concept that only patients with the capacity to pay can access healthcare is what has been challenged by the Right to Health Act. It seeks to strengthen the public health infrastructure and holds the government responsible for the services.

The Union government claimed to have budgeted 2.1 per cent of its expenditure in 2022-23 for health, but in fact the Union health budget has hovered at around 1.5 per cent since 2015, with a marginal increase post-pandemic. In popular perception, private hospitals have thrived thanks to reimbursements under various state and Union government schemes.

Anecdotal evidence claims that medical insurance companies reimburse close to Rs 65,000 crore to private hospitals every year. A major chunk of the reimbursement is claimed for ‘fever of unknown origin’ which allows hospitals to conduct any number of tests which the insurer is unable to question. That private hospitals prefer patients with medical insurance is also well known. These cater largely to the better-off middle class comprising just about 10 per cent of the population. Much of the government’s spending on health insurance, it is suspected, is cornered by those who do not need it.

India, it is acknowledged, provides first-rate medical facilities and world-class care to the affluent. Promoting medical tourism is seen as a legitimate goal and NRIs often prefer to get medical care in India rather than abroad. While the costs are often prohibitive in the United States, in most European countries which offer universal healthcare to people, the waiting time is usually long and appointments and procedures are not offered on demand but according to urgency and need.

Dr. Pavitra Mohan, co-founder of Basic Healthcare Services, a Rajasthan-based non-profit, questions Niti Aayog’s recommendation to privatise district hospitals, and the premise that most Indians seek healthcare from private facilities.

The argument is flawed, he wrote for National Herald, because most of the people in rural India continue to be dependent on government facilities for most critical healthcare needs. In rural Rajasthan, 98 per cent of childhood vaccination, 70 per cent of contraception, and 79 per cent of institutional childbirths are conducted by government healthcare facilities, he pointed out.

A Public Health Foundation of India study, published in the British Medical Journal, claimed that expenditure on healthcare in India pushes 55 million people into poverty every year—even as healthcare expenditure as a percentage of GDP at an all-India level fell below 1.3 per cent in 2018 for the first time since 2004- 2005, before picking up to 2.1 per cent in 2022-23.

Rajasthan allocates about 6 per cent of its annual state budget to healthcare, which is higher than several states but is still seen to be inadequate. The National Health Policy of 2017 recommended that states spend at least 8 per cent of their state budget on healthcare. None of the states including Rajasthan, where the annual health budget is Rs 30,000 crore or so, is anywhere close to that target.

There is a well-founded suspicion that doctors and private hospitals in Rajasthan have hijacked the Right to Health Act, and are holding it hostage. Substantially diluted under pressure, the industry lobby also seems to have succeeded in getting the state to drop the provision of inducting representatives of patients and civil society to monitor the implementation of the Act. Doctors apparently insisted that no ‘outsider’ should have any say in its implementation.

While the fine print will only become clearer in the coming days, the pioneering Act is clearly a step in the right direction. One hopes that independent social audits will lead to improvements and course corrections along the way.