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Jul-Sep2002-10(3)
EDITORIAL
Time to
Act?
SP Kalantri
Over the last year, discussions have taken place
towards amending the 53-year-old Bombay Nursing Home Registration Act in
Maharashtra. The new legislation would be called the Maharashtra Clinical
Establishment Act. The proposed bill is a significant milestone and the focus of
intense debate.
In 1991 the Mumbai group of Medico Friend Circle
filed public interest litigation jointly with an aggrieved citizen, whose father
died following mismatched blood transfusion in Mumbai. The Court asked the
Municipal Corporation to set up a committee to refurbish the outdated and poorly
implemented Act. The committee's report and a subsequent in-depth study of
private healthcare providers in Satara (1) contained shocking findings:
according to the survey, only a quarter of practitioners were qualified; 62 per
cent kept no medical records; most nursing homes employed unqualified and poorly
paid nurses and lacked the equipment, space and infrastructure to ensure patient
safety. Not one hospital was registered with the local authority. Still, the
government slept over the studies for almost a decade. The wake-up alarm appears
to have come from a World Bank- funded Health Systems Development Project to
standardise private health services in Maharashtra. The state government is
likely to table the draft for discussion soon and is keen that the bill is
passed. The Andhra Pradesh government has passed a similar bill in March 2002.
Private insurance is watching these developments with interest.
The draft proposal was discussed in July 2001 with
representatives of consumer health groups, medical professionals, owners of
nursing homes, and other organisations concerned with health. These
associations, which have a stake in updating regulation of health sector, played
an important role in shaping the discussion on the proposal. Many issues were
touched upon in the course of these and subsequent discussions. Some of these
are: redefining 'clinical establishments'; dealing with their registration and
re-validation and appointing competent authority to do so; classifying
healthcare establishments with reference to different standards and to require
them to conform to the standards regarding staff, equipment, facilities etc;
participation in national health programmes; penalties for flouting the rules;
requiring clinical establishments to display their fee structure, and ensuring
patients' access to their health records.
How does the proposed bill differ from the current
Act? One, it covers all healthcare sectors - public, private and
non-governmental - and systems (allopathy and alternative) across the
state, a commendable step indeed. Second, mandatory registration, re-validation
and common minimum standards would improve the quality of health care. Third,
patients will be better informed about fees and intervention charges and would
have access to their medical records, should they so wish. Fourth, depending
upon its final formulation, the amended Act could ensure that private healthcare
providers respect the rights of patients with HIV to receive healthcare without
discrimination. Finally, the Act, if implemented in the intended spirit, can
check the proliferation of poor quality clinical establishments.
The intentions are laudable, but the proposed
amendments must ensure that the final Act includes the logistics of implementing
it. These logistics have not been worked out adequately in the draft available.
The private sector's knee-jerk response is that it will have to pay more for
registration, face what it considers intrusive and overbearing regulators and
see an increase in its paperwork. It is for the government to ensure that these
fears are irrational. The authorities must discharge their duties effectively,
involve stakeholders in the decision-making process, and be accountable to them
to enable confidence in their performance. Given the government machinery's
competence and commitment, perhaps this is asking for too much. The proposed
bill covers traditional and alternative systems of medicine. But how will
alternative practitioners be judged? Against the skills of those in the same
field or those of orthodox medical practitioners? Some of these systems lack
statutory councils and ought to be governed by separate
legislation.
The new bill proposes some minimum standards for
registering clinical establishments. Experts, not a clinical establishment
board, should develop guidelines, which are rational, evidence-based and
sensitive to the needs - and realities - of rural health care. The amended Act
should link professional standards of practice with registration and
revalidation so that individual doctors can be accounted for their competence,
performance and conduct.
Identifying a negligent doctor in the private
sector is easy. But not so in the public sector. Given the appalling standard of
public health care, the government will have to work hard to ensure that public
health providers flouting standards and rules do not escape
punishment.
Information, autonomy, power - an Act so graced
will be an achievement. While the public sector has suffered from excessive
bureaucratic controls, the private sector had neither control nor regulations,
and for five decades resisted the concept of minimum clinical standards.
Tightening regulation could be the first step towards achieving good clinical
care. It could provide much-needed teeth to the consumer and the government: it
is up to them to use them judiciously. For, regulation alone, as we know from
our experience with the MCI and the Consumer Protection Act, is not enough. Nor
does it necessarily change doctors' behaviour. It must be backed by an alert
citizenry and a proactive government.
Reference: 1. Nandraj S, Duggal R. Physical
standards in the private health sector: a case study of rural Maharashtra:
www.cehat.org/initiatives1.html
Dr SP Kalantri,
Department of Medicine, Mahatma Gandhi Institute of Medical Sciences,
Sevagram, Maharashtra. Email:sp_kalantri@rediffmail.com