In a first of its kind action within the federal polity of India, the state of Rajasthan last week pulled through its legislative process a Bill ensuring the right to health for all its residents.
In its intention and formulation, the state leadership is to be congratulated, as the Bill – now an Act – builds on previous actions to reduce catastrophic out-of-pocket health expenditure, as well as expand the range of health services that can be accessed by the people of Rajasthan using their Chiranjeeevi cards. This Bill contrasts in its framing with the public health Bill that the Kerala assembly passed a few days earlier. The Rajasthan Bill seeks to operationalise health as a right, while Kerala, further along on its health continuum, sought to bring coherence to its public health approach – the right taken for granted by the relatively healthier population of the state.
Article 21 of the Constitution of India has enshrined the fundamental right to life for all Indians. Substantive rulings from constitutional benches of the Supreme Court of India have read in a right to health within the ambit of this right. This expanded reading makes space for legislative and administrative mechanisms that ensure outcomes of this right are enjoyed by all Indians. It also protects the possibility for any Indian to seek redress for the curtailment of this right to health. The only missing bit is a formal definition – is the right a guarantee of medical care for a set of conditions at the individual level, or the assurance of a set of enablers that together would yield outcomes like the absence of disease, and physical, mental and social well-being?
The constitutional bifurcation of responsibilities between the Union government and the state governments places health in the concurrent list, allowing for both to act in concert towards realising this right. Given compulsions of political economy in general, and real constraints in available finances, health isn’t prioritised – at least until more recent times, and now it seems explicitly top of mind in Rajasthan. Health is also marked on the expenditure side of budget sheets rather than on the investment side – a sad misunderstanding of the nature and value of human lives and their role in shaping the output of the nation.
Against this backdrop, India is committed to achieving the 17 UN Sustainable Development Goals by 2030, and especially Goal 3 which pertains to health and has very specific indicators of success. India’s constitutional and global commitment for health of its people is translated into reality at the state, district and panchayat or urban body levels, leveraging the large tax-funded public healthcare delivery infrastructure as well as the robust private healthcare services sector. Both the public and the private are important in the achievement of health, though they may at times appear to work at cross purposes by misunderstanding the basic obligation of every healthcare service provider to avert unnecessary death and morbidity at the first possible instance.
An alive person is a far better outcome than the expense averted in not delivering that lifesaving intervention. The Rajasthan Right to Health Bill of 2023 does not make that goal explicitly clear, nor make it an indicator of its successful implementation. Also, the presentations of life threatening conditions necessitating time sensitive interventions varies by age and gender – an older person is more likely to present with a blackout following diabetic ketoacidosis, while a younger person may more likely be the unconscious one presenting with a poisoning.
Besides the “accidents” and “emergencies” defined in the Bill, acute myocardial infarctions, impending suicides, diabetic ketoacidosis, neurological strokes, acute asthma, profound fluid or blood loss – all of these and many more conditions are emergencies requiring time sensitive, lifesaving response at the first healthcare facility possible. Defining a basket of conditions where the first response is standardised and is auditable (and reimbursable if the delivery point is a private sector facility, and the patient lacks means to pay) will be a huge next step.
In indicating that there be a “Rajasthan Model of Public Health” and also constituting two mechanisms of oversight and redressal – logistics, and treatment protocols, at the state and district levels – there is scope for some of these ideas to be woven in and implemented. Every healthcare professional and healthcare establishment in the state, irrespective of their public or private nature, need to be engaged and indemnified for the delivery of life saving, morbidity limiting, first point of care service. It will need robust assessment and imagination, of ways in which emergencies are attended to within the time frames of usefulness, and of means of ensuring that there are accountable expenditures. This is where the logistics and treatment protocols wings of the State Health Authority should engage with counterparts in the ministries of roadways, telecommunications, and law enforcement, to name a few.
Doctors in Rajasthan, mostly those who work in the private sector, have been protesting against the Bill. Photo: Twitter/@FordaIndia
Beyond the obligation to provide quality assured mortality preventing and morbidity mitigating first level services for a range of conditions, Rajasthan’s health infrastructure should be able to address all other elective and non-emergency needs of its resident population, based on guidance from the treatment protocol wing of the State Health Authority. National priority programmes funded by the Central government – like the TB or blindness control programmes – should be interwoven into the reimagined and revamped delivery network by the logistics wing, making it an integrated one rather than being fractured along funding lines.
While working its way through the formulation of the Rajasthan Model of Public Health, it will be incumbent on those framing it to work out the “minimums” of primary, first point of care lifesaving services deliverable, standards and costings for each as well as for non-emergency services. These would translate to rolled up totals for the extent of budgetary allocations required. Where practical, the health insurance mechanism should be rolled out to cushion the state, and individuals, from impoverishing costs. Reimbursement of expenditures to the private sector based on protocols based audits should become seamless. Also, regular training and evaluation for every healthcare worker and delivery point needs to be in place to ensure evenness of quality of service delivered. These “minimums” are to be publicly conveyed, and local representatives and voluntary agencies will need to be engaged in helping residents of the state to understand the scope of their right to health.
The Rajasthan Right to Health Bill lays out a detailed grievances redressal mechanism. With life threatening situations, and in instances when despite best efforts lives are unfortunately lost, emotions and tempers are usually frayed – and recourse to formal grievance redressal mechanisms are the last things on the aggrieved minds. This is an area that requires an explicit commitment from the state towards every single healthcare professional, that there would be zero tolerance for violence directed to them. This would be the counterpart guarantee to the assurance of no harassment to bystanders and neighbours who bring in individuals requiring emergency services. When both of these are robustly implemented, the disinclination to get involved in saving lives as a bystander or as a healthcare professional will dramatically decrease.
Healthcare professionals work in best of times under a fair bit of stress – and infallibility is not to be expected, especially when confronted with emergencies and resource limitations. The same is applicable to those who will be hearing grievances against the healthcare professionals. It would be ideal that there be no explicit indemnification for members of the State and District Level Authorities as is currently stated in the Bill; instead, a high bar may be set for bringing a complaint against their decision making, and a state health ombudsman be appointed. This would go a long way to allaying apprehensions of those in the private sector.
It is heartening that the Bill sets out a non-discriminatory approach – and refers to everyone who would seek healthcare services as residents. Rajasthan is a magnet for tourists – from within India and abroad. And when people are away from home, health emergencies can be more stressful. A good, non-discriminatory, first point of care healthcare network comprising of public and private facilities, providing a quality-assured basket of early lifesaving and morbidity averting services will make the state an even more attractive and safe destination.
Bobby John, a physician and public health advocate, is the founder of Aequitas Diaqure, a biotech focused company.