Rajasthan Right to Health Care Act, 2023: What it Entails, and How We Got There

The Act will enhance access to assured free quality healthcare as far as possible to people, thereby reducing morbidities and premature mortalities, along with promoting heightened health awareness. This one-of-its kind enactment could set an example for other states of India to emulate.

—

What is the significance of the right to health legislation recently passed in Rajasthan?

The legislative assembly of Rajasthan recently passed an Act to provide health rights to its citizens. The Rajasthan Right to Health Care Act, 2023, passed on March 21, has created history of a kind as no other state in India has bestowed the right to health by enacting such a law.

The Act is consistent with the right to life under the Article 21 (protection of life and personal liberty) of the Constitution, which has been interpreted by the Supreme Court to entail the right to all basic needs required to live with dignity. The Supreme Court has held that it is incumbent upon the State to ensure that nobody remains deprived of such needs.

A Right to Health Act further supplements the already existing legislation providing the rights to food, education and employment, among others. If implemented in its true spirit, it could, by enhancing access to free, high-quality medical care and healthcare, significantly reduce morbidity and preventable mortality. A healthy society, after all, is more productive and agile.

Why was the Act needed in Rajasthan?

Rajasthan has a population of around 80 million, and is the largest state in terms of geographical spread. Its health and economic indicators put it among the low-performing states in the country; therefore, the enactment of a right to health legislation is an expression of the government to enhance access to quality healthcare without any catastrophic expenditure by families.

Even prior to legislating the Right to Health Care Act, the current ruling party in Rajasthan launched a slew of schemes to improve access to medical care in the state, such as a scheme for free medicines, the chief minister’s free treatment scheme, and health insurance through the Chiranjeevi scheme.

It was this writer who suggested to the political parties contesting 2018 Rajasthan Vidhan Sabha elections to commit to the right to health in their manifestos. The writer gave detailed reasons for why it is essential. However, only two parties included it in their manifestos; one out of them ended up securing a majority in the Vidhan Sabha and formed the state government. After winning the elections, the party converted its election manifesto into the official government commitment document.

Even prior to legislating the Right to Health Care Act, the current ruling party in Rajasthan launched a slew of schemes to improve access to medical care in the state, such as a scheme for free medicines, the chief minister’s free treatment scheme, and health insurance through the Chiranjeevi scheme, which assures insured families of five persons up to ₹10 lakhs of medical coverage treatment at government and empanelled private hospitals. In the recent state budget announcement, the sum insured under the Chiranjeevi scheme has been enhanced to ₹25 lakh from the financial year 2023–24 onwards.

In spite of these provisions and schemes, residents of the state continued to bear around 60 percent of their health expenditure out of their pocket, as per the National Health Accounts 2018–19 released last year. As a consequence, families lost on their savings, nearly 7 percent of the country’s population slid into poverty year (as per National Sample Survey Office estimates), and a significant number of people seek either no medical care while sick or avail treatment from unqualified quacks, which could cause more harm than good in the long run.

One of the reasons behind this is that citizens did not get full benefit of the schemes since these are not entitlements, so their breach or non-availability of services is not tantamount to violation of any right. The enactment of the Right to Health Care Act obligates the government to ensure health services as needed for citizens, without causing additional hardships.

What was the journey traversed by the Act to get passed in its present state?

The passage of the right to health legislation in Rajasthan has been the culmination of a turbulent, chequered path. The process of drafting the Bill began soon after the Indian National Congress party came to power in the state in December 2018. The Jan Swasthya Abhiyan Rajasthan, the Rajasthan chapter of the Jan Swasthya Abhiyan, a national network of civil society organisations and people’s movements working for health rights, formulated a draft law and presented it to the political executive of the state.

Later, a committee was constituted by the state to fine-tune the draft law, of which the writer was a member, but even the draft prepared by the committee was considered to be too radical for the state government to commit to.

Due to the doctors’ protest to the introduction of the Bill, it was decided in the Vidhan Sabha that the Bill be referred to a select committee of legislators to seek more inputs and to suggest amendments. A 16-member select committee was constituted, headed by the state’s health minister.

This draft had suggested that the state government should commit to providing basic primary healthcare to all residents within half an hour of walking distance from their residence, comprehensive primary healthcare within 10 km of their residence, all emergency care within a distance where a patient could reach within an hour by a motorised vehicle, tertiary level care at a maximum distance of 80 km from their residence, and super-specialty treatment within 150 km of their residence. This Bill also provided that the health budget should be about 6 percent of the state budget or 2 percent of the Gross State Domestic Product.

The Bill had clauses for a robust grievance redressal system through the designation of complaints officers in every medical institution, the provision to file complaints against treatment procedures or logistics via phone on designated number, a web portal or in writing, and the creation of appellate authorities at block, district and state levels fully empowered to adjudicate on grievances. This draft provided for the creation of forums to receive regular feedback from the citizens by holding public dialogues and carrying out social audits. It also provided for developing a policy for the transfer, promotion and career-building of all kinds of public sector healthcare providers in order to build in the element of equity and fairness among them.

But nothing moved after the COVID pandemic struck the globe, and the movement resumed only in late 2021 with a new draft of the Bill. This had general obligations and commitments to provide free healthcare services; how and in what quantum these services were to be provided was left to be decided through rules framed by the government under the Act. This draft provided for health authorities at the levels of the state and the districts, to be headed by bureaucrats and public representatives, and comprising public health experts and civil society representatives as members.

However, when a draft Bill was put on the official website of Rajasthan’s Medical, Health and Family Welfare Department for comments in March 2022, it was found to have been further modified and toned down in scope and mandate.

A new clause added to this draft stated that private hospitals would treat emergency patients without any payment. This clause expectedly infuriated private doctors and their organisations. The comments submitted by them vehemently opposed this clause, besides arguing that there is no need for such an Act at all.

Their argument was that the health sector is already overregulated, and that everything is going on fine. Private hospitals already treat about 60 percent of all the patients, so they must not be burdened any further, they argued.

Many civil society organisations including Jan Swasthya Abhiyan Rajasthan, in their comments suggested the strengthening of the Bill, especially provisions related to the grievance redressal system and community engagement, as well as recommended a clear commitment about the budget and the availability of services as per distance norms and population.

The government finally introduced the Rajasthan Right to Health Bill, 2022 on September 22, 2022 in the Vidhan Sabha for discussion and passage. Many legislators participated in the discussion, mostly from the opposition parties.

At the same time, doctors’ organisations staged vehement protests against the introduction of the Bill. They took out a protest march and it was decided in the Vidhan Sabha that the Bill be referred to a select committee of legislators to seek more inputs and to suggest amendments. A 16-member select committee was constituted, headed by the state’s health minister.

The committee held several rounds of discussions with representatives of doctors’ organisations and accepted most of their demands:

• That if the patient does not pay, then the government would bear the cost of treatment done in emergency by any private hospital;
• That public representatives, civil society members and public health experts be removed from membership in the district and state health authorities, and be replaced by two representatives of the Indian Medical Association (IMA);
• That there should be only a single line of grievance redressal, and any person with a grievance must only complain in writing to the head of the institution to which the complaint pertains to.
• The district authority would be chaired by the district collector, and there would be two state authorities— one for logistics and the other for treatment protocols. The state authority for logistics would be headed by an Indian administrative services officer of the rank of secretary, the more important one on clinical protocols would be chaired by the vice chancellor of the Rajasthan University of Health Sciences.

The Rajasthan Right to Health Care Act, passed on March 21, now entails a general government commitment to provide all curative, preventive and health promotion services to all citizens of the state in the manner decided by the state government in the Rules framed under the Act, and the constitution of state and district health authorities to advise the government, monitor implementation of the Act and function as appellate authorities to adjudicate on grievance complaints.

The Act entails a general government commitment to provide all curative, preventive and health promotion services to all citizens of the state in the manner decided by the state government in the rules framed under the Act.

The Act does not specifically mention the length and breadth of the state’s commitments in numbers; they too have been left to be notified through the Rules.

Why are private doctors and medical establishments protesting against the Act? Are their protests justified?

However, as the business advisory committee of the Vidhan Sabha announced the date of discussion and passage of the bill, doctors went up in arms to oppose its passage and demanded that there be no right to health. They took out a massive protest march, and attempted to cross barricades put up around the Vidhan Sabha to restrict traffic and scuffled with the police there.

Since then, all private health establishments of the state have closed their doors to patients, and government doctors are working with black ribbons tied on their arms in solidarity with the doctors of private establishments. Now, doctors have even begun hunger strikes, and have, in some places, called for fast unto death. As a result, medical care in the state has been disturbed, especially for those seeking care from private hospitals.

The exact reasons why the doctors are agitating are not clear because the Act has little to do with the private sector. Their demands pertaining to the cost of treatment of patients in emergency wards of private hospitals, the refusal of representation of public representatives in health authorities, a single window grievance redressal, and membership of IMA representatives in the health authorities have been accommodated in the Act. The Act has also defined the emergencies as only those which could be related to accidents, snake bites and obstetrics. Private hospitals are required to provide only emergency care till it becomes possible to transfer patients to appropriate hospitals without any possibility of deterioration in their condition The Act also clearly mentions that the treatment cost would be borne by the government, if not paid by the patient as per the decided rates.

The Act also mentions that the treatment cost would be borne by the government, if not paid by the patient as per the decided rates.

It is being envisaged that the Act would enhance access to assured free quality healthcare as far as possible to people, thereby reducing morbidities and premature mortalities, along with promoting heightened health awareness. This one-of-its kind enactment could set an example for other states of India to emulate.

Dr Narendra Gupta is Coordinator at Prayas, a voluntary organisation working for social, political and economic development in the Chittorgarh district of Rajasthan.