Clinical Establishments Act 2010
The National Health Policy 2017 was notified last week. Coming 15 years after its predecessor, it presented an opportunity to do things differently. First, the recognition that strong state intervention is needed to control the surge of diabetes, heart and respiratory diseases hasn’t come a day too soon. With early screening and diagnosis becoming a public responsibility, the lives of millions of Indians could be saved from debilitating illness and premature death. This shift in emphasis is noteworthy.
Second, establishing a professionally-managed state public healthcare cadre makes eminent sense. A dedicated cadre of healthcare professionals can detect state-specific health hazards and contain them before they spread. The inclusion of professionals from sociology, economics, anthropology, nursing, hospital management and communication is a recognition of a multi-disciplinary approach and an acknowledgment that cultural attitudes must be understood if public health strategies are to gain community acceptance.
The third takeaway is the goal of pushing up male sterilisation “by 30 per cent and, if possible, much higher”. After Sanjay Gandhi’s blighted nasbandi programme, even the mention of male sterilisation made political parties, particularly in North India, squirm. Even after four decades, no politician was prepared to listen, leave alone act. Putting male sterilisation upfront also exhibits concern for the plight of women, who, after dealing with unwanted pregnancies and repeated childbirths, also undergo harrowing tubectomies. Thailand successfully made vasectomies into a routine affair more than 25 years ago. If six Indian states that account for almost half of India’s population and its annual growth, can incentivise (not coerce) men to limit family size by sterilisation, it could be a game changer.
The fourth good idea is piggy-backing medical and paramedical education on service delivery. Generations of health planners have been telling the Medical Council of India to factor in the ground realities that reduce the relevance of even the best medical curriculum. Indeed, students and patients would gain vastly if such facility-based training gets implemented.
The fifth half-positive takeaway is the recognition that AYUSH needs to be integrated into the research, teaching and therapeutic components of health systems; stressing that traditional systems need to back their claims with evidence is equally positive. But by repeating the unsuccessful strategy of appointing contractual AYUSH doctors in primary health facilities, the policy goes into reverse gear. AYUSH practitioners posted in PHCs do precious little traditional medicine and simply function as spare wheels or substitutes for allopathic doctors. That pads up manpower shortfalls but devalues the strength of AYUSH. Had the policy supported recognition of approved district specialty AYUSH centers for a host of chronic problems, lakhs of patients in search of reliable AYUSH treatment could have benefited.
The policy has neatly sidestepped some basic concerns. The Clinical Establishments Act 2010 was passed by Parliament with the aim of regulating clinical standards, both in the private and public health sector, and ending quackery. It has received scant backing from the state governments and was rejected by the Indian Medical Association. Instead of emphasising the importance of oversight of all medical establishments, the policy has soft-peddled by recommending mere “advocacy”.That leaves a hapless public at the receiving end of much care, malpractice and exorbitant treatment costs with no protection. Leaving health regulation up in the air with talk of yet another standard-setting organisation will not insulate consumers from exploitation.
The policy is also hazy about generating resources. One wonders whether the reference to medical tourism earnings and “a high degree of associated hospitality arrangements” implies a desire to tax hospitals that offer frills. This sounds egalitarian but could drive away the relative advantages that Indian medical tourism presents.
The policy places enormous reliance on the eighth standard-pass female volunteer, ASHA — the lynchpin of the National Rural Health Mission. But it does not even allude to how the poor, both in rural and urban areas, are driven by a desperation to overcome acute illnesses (that result in a loss of wages) to seek medical treatment from quacks, RMPs or self-styled doctors with no medical qualifications. Fluff about upgrading sub-centres or providing additional multipurpose workers does not confront the pervasiveness of RMPs or jhola chaap doctors who administer IV fluids, antibiotics and steroid injections with impunity. The policy shows no recognition of the magnitude of what is happening on the ground, even when a WHO report shows that unqualified medical practitioners constitute more than half the “doctors” in India. The WHO’s report is based on data provided by the Census office and the erstwhile Planning Commission. Recognising that they cannot be wished away, the West Bengal government has even embarked on training quacks “to cause less harm”. This problem is too pervasive to be ignored. The policy should have confronted it.
The policy has rightly explained why the time is not ripe to make health into a justiciable right. It is good that symbolism hasn’t held sway as it did with the impractical Right to Education Act. What is more important, however, is for the states to accept the policy and implement the law. It is time that registration, accreditation and regulation of clinical establishments and standards is put in the Constitution’s concurrent list in much the same way as drugs, food and medical education. Too much is at stake to be left to the states that often look the other way when it comes to maintaining critical health standards — this is something that ought to be non-negotiable.
The challenge now is to translate the policy’s stated noble intentions into schemes and programmes supported by the requisite financial backing. It is accountability that needs early deliverance.
The writer is former secretary, Department of AYUSH, government of India, and former chief secretary, government of Delhi