Why doctors are wrong in opposing Rajasthan health bill

In opposing a Right to Health (RTH) bill and holding protests in Rajasthan and across the country, we physicians seem to have lost our way. Rajasthan is the first state in India to propose health as a right.The state is taking legal responsibility to provide healthcare to all residents, who can sue government if unable to access healthcare once the bill is law. This is a huge step in the right direction. Only implementation and time will tell how well it works, but it’s a start.Question of ethicsThe vehemence of the opposition by doctors and their associations – those who ought to have been at the forefront to push for a right to healthcare – is surprising; the RTH bill attempts to improve healthcare delivery primarily through improved public health or state-funded treatment in private entities. The main point of contention is emergency services. The bill mandates delivery of care of a broad set of “emergencies” by private hospitals. Some anxiety is understandable – not all health facilities are equipped to handle emergencies. Mapping of institutions – which will deliver what type and level of emergency care – is not yet clearly defined. As per Association of Healthcare Providers of India, small hospitals with 11-50 beds make up 65% of India’s private hospitals; those with under 10 beds constitute 14%. Most of these will be unable to handle emergencies and hence it is important to identify hospitals capable of providing emergency care. An emergency such as massive trauma can require a multi-speciality approach and cost a lot to even stabilise. Payouts for these can only be defined under rules made under the law, and not in the bill. Rather than engage with the process of making these rules, doctors and hospitals seek that the law itself be scrapped.The Supreme Court has several times mandated that no one can be denied emergency care. Physicians should remember taking care of patients in an emergency without payment if necessary is also part of the ethics regulation of Medical Council of India (2002). ShowBlurbsPrivatising healthcareThe problem is that private entities have become the predominant mode of healthcare delivery. Providers’ resistance stems from the core idea that healthcare is an “industry”, not a service, and like all industry should generate profits. Healthcare providers in general and doctors, in particular, have internalised the idea that “market forces” determine access to health; those who cannot pay for it can, in some extreme views, “lump” it or be “dumped” in public hospitals. Multiple state and central governments have promoted this notion and added to the distress by withdrawing from their responsibility of delivering quality accessible healthcare and by accelerating privatisation of healthcare.Lack of public healthcare has forced people to private healthcare. In Rajasthan, public facilities account for just 43% of outpatient consultations in rural and 32% in urban areas. Public facilities account for half the hospitalisations and 77% of childbirths. The new law promises to strengthen the public sector, which could help reduce the reliance on private sector.A bad situation has been made worse by corrupt practices in many private health facilities like over-billing, fake billing, over-prescribing, and unnecessary tests and procedures. Even governments have struggled to keep them honest while reimbursing. That said, unrealistically low reimbursement rates for procedures or packages push providers to make false invoices.Severe financial distress due to out-of-pocket expenditure on medical care is a reality. A Parliamentary Standing Committee report in 2016 stated that nearly 63 million people were pushed into poverty annually due to “catastrophic health expenditure”. medium99192695Govt, bring clarity, show the money medium99192232Dealing with trust deficitDistressing healthcare costs, declining trust in healthcare system and difficulty of legal recourse have led to violence increasing against healthcare workers and particularly doctors, seen as the face of the system. Unfortunately, most times the violence is directed at the juniormost doctor, who is just a cog in the wheel and possibly as exploited. The trust deficit and expenses have also led to a lack of acceptance of negative outcomes, sometimes in spite of the best possible care.In this context, some states and the Centre have devised insurance and emergency care schemes that allow access to private healthcare facilities at best in a piecemeal manner. Rajasthan’s RTH bill attempts a more broad-based healthcare delivery system, in a state without a good public health system and fairly mediocre health indices. The focus is to improve public health services while buying from non-government entities those tertiary and emergency care that public health lacks. This is how we need to see the bill.It is unfortunate doctors oppose it. It increases the trust deficit as it reinforces people’s belief doctors and hospitals are only interested in profits. This is also why politicians get away with abusing and attacking doctors and make them scapegoats for inadequate healthcare systems. It is in our interest to negotiate changes in the bill’s provisions rather than oppose it wholesale. I urge the profession to re-engage with what should be its natural ethos and not become party to vested interests or profit motives of a section of our profession that can only further damage the patient-doctor relationship.The writer is an intensivist and medical director of a not-for-profit hospital in Delhi.