Rajasthan law raises the bar for state health facilities

Civil Society News, New Delhi

A new law in Rajasthan that gives every citizen the right to free public healthcare has the potential to raise the standards of medical services in the state and make them more accessible and relevant to the needs of people.

The law commits the government to ensuring health infrastructure is in place and that its clinics and hospitals are more inclusive and responsive. It could serve as a model law for other states interested in ensuring that quality healthcare reaches people, especially those who are needy and underserved.

The law, however, has been mired in controversy with doctors belonging to the Indian Medical Association (IMA) going on strike over a provision that stipulates free treatment in private hospitals in the event of emergencies, such as accidents, with the government reimbursing the costs.

The Rajasthan state government finally decided to reconsider the provision on emergency services so as to end weeks-long disruption in medical services. But the agitation drew public attention away from the real issues involved. Lost in the din were the many important ends that the law is intended to serve.

High up on the list is the goal of energizing the healthcare system by strengthening the primary health centres (PHCs) and sub-centres and the district hospitals in the tier above them. This would take away the load from tertiary facilities.

A better PHC system would make it possible to treat people closer to where they live. It would also lead to the detection and treatment of diseases in their early stages. The law commits the government to adequately staffed and equipped health centres.

“It is an important law because it comes at a time when the talk is all about privatization and the use of insurance to provide healthcare. But with this law the government commits itself to providing free healthcare with dignity to every citizen at state-run facilities,” says Dr Pavitra Mohan, co-founder of Basic HealthCare Services in Udaipur. Dr Mohan is one of the rural doctors whose work this magazine tracks.

“The government is saying it will have in place infrastructure, staff, medicines and diagnostics. The citizen can now demand these from the government,” says Dr Mohan, who is a pediatrician and public health practitioner.

“At the primary level it is only the government system that can effectively reach people and meet their needs. We have seen during Covid-19 the important role played by government-run facilities,” he says by way of example.

Basic HealthCare Services runs six primary health centres in rural Udaipur. It also runs a government PHC which it has adopted. The emphasis at these PHCs is to move away from doctor-dominated healthcare services to empowering nurses to monitor patients and take decisions under the supervision of doctors. There is also training of local women to serve in the PHCs.

When PHCs are located within reach, the community benefits from regular monitoring and easy communication. No one has to lose wages to travel to a health facility. Local women trained to be Auxilliary Nurse Midwives or ANMs and nurses engender trust and familiarity, making it simpler for patients to approach them. The bridging of cultural and linguistic divides is essential for delivering healthcare. So too the fear of medical interventions that comes from lack of knowledge.

Dr Mohan says PHCs are successful when there is teamwork. Typically, at the PHCs that Basic runs there is a doctor and nurses and ANMs. But whether the doctor is there or not, the PHCs are functioning and effective because everyone is engaged in running them. High levels of motivation are important.

“How successful the law is will depend on the rules for implementing it. The government has to motivate doctors to serve in rural areas and provide the facilities they need. The salaries the government pays young doctors are good enough. But they should also feel that they have opportunities for professional growth,” Dr Mohan explains.

The rules will also have to work their way around problems such as locating PHCs. Currently, the provision is for a PHC for every 25,000 people. But in southern and western Rajasthan people live in small clusters and a population of 25,000 could be spread over 100 km. The rules will have to deal with local realities for the law to be effective.

“In Rajasthan, the basic infrastructure exists,” says Dr Mohan. “You will find a doctor and nurses in a PHC. Medicines are free. But the quality of the infrastructure, availability of medicines and the commitment of the doctors and nurses is where the challenge lies.”

Much work clearly remains to be done even though Rajasthan ranks among states that have something to show by way of public healthcare. Going forward implementation of the law will require the involvement of public-spirited doctors and voluntary groups in Rajasthan.

The Rajasthan law itself comes out of the efforts of non-profits like the Jan Swasthya Abhiyan. The Congress had promised in its manifesto in the last state elections that it would make free healthcare a right. The promise has been fulfilled with the passing of the law which came out of wide consultation and the experience of voluntary groups.

The right to healthcare was, in fact, first proposed at the time of the National Health Policy. But it wasn’t included and it was decided at that point that it should be left to the states to legislate on.

Rajasthan’s experience will be useful for other states, especially those which already have medium to good infrastructure in place. For those lower down the ladder of development, the challenge is going to be more complex.

But passing the law is an important step in the state government coming forward to spend more on health and take responsibility for reaching health services to those who need it most. It also creates some hope of restoring balance in the healthcare market where privatized services are in a dominant position but aren’t the solution to universal care, which alone can reach large numbers.