After a long and tortuous journey of 35 years, the Goa government finally passed the Clinical Establishments Act (CEA) in 2019 and gazetted the rules in July 2021. This was a laudable landmark even if comments and suggestions were called for after the bill had been gazetted.
The saga started in 1986, when the Goa Assembly passed the “Goa Daman and Diu Private Nursing Homes (Regulation) Bill of 1986”; (Bill No.29 of 1986). It even made its way to the Gazette (page 378, series 1-20), signed by Sheikh Hassan, the then Health Minister. As the Rules were not framed within the six months stipulated by parliamentary procedure, the Bill lapsed. Why it happened is a matter of conjecture. Probably a combination of bureaucratic and political apathy because healthcare issues like this do not have a vote bank; compounded by singularly blinkered vision by the professional fraternity. For example, at a seminar “State of Goa’s Health” in 2000, the days deliberations were summarized and presented to the then CM for his closing remarks. When the urgent need for such an Act was highlighted, his reply was “the more rules you have, the more people break them”. There the matter lay dormant, in spite of repeated representations, till the late Sushma Swaraj as health minister directed all States to enact such a bill. When they failed to do so a Central bill was introduced in 2007. States had to either adopt the Central Bill or adapt their Bill if they already had one. A fresh draft was presented to the health minister in 2013 in Goa. With the draft lying with the Law Secretary, my interactions with the late Manohar Parrikar in pursuit of this bill, resulted in his comment in public forum that the Law Department was like a black hole where matter entered and nothing came out!
They say your sins eventually catch up with you, and so they did in this case too. When the current pandemic burst upon us, the government was rightly obliged to commander hospital beds in the private sector; and with it came the realization of the regulatory vacuum. Basic essentials like oxygen capacity and storage were found lacking. ICUs, monitors and various other electrical equipment running at full capacity round the clock, overloaded antiquated electrical systems and set off fires. Goa was comparatively lucky; but the lack of regulations was highlighted by such adverse events across the country.
Why should such regulation be necessary at all? Quite simple; a patient has the right to know what to expect when he decides to get admitted into a particular hospital. There have to be some established minimum standards and grading, to qualify for the description ‘Hospital’. Does the hospital employ nurses with qualifications recognized by the Nursing Council? Can the patient expect to be attended by qualified R.M.O.s at 2am?’ Does the hospital have a 24hr pharmacy with a qualified pharmacist as specified by law? Or will the relatives be expected to go hunting for a vital drug at 3am on the unpoliced streets of Goa, where public transport is non-existent after 9pm. These and many other such issues are practical problems that only patients and their relatives will appreciate. The point being that the State has to exhibit sufficient concern to anticipate such problems and provide for such contingencies. To the neutral observer, it appears ridiculous to shut down “gaddas” selling omelet pao because they do not have a license to operate, yet permit hospitals which deal with life and death situations, to function totally unregulated and unaccountable. It is extremely reassuring that the Bill addresses most of these issues. Hospitals are graded; Level 1a, 1b, 2, 3 (non-teaching) and 4, the teaching category. Each grade must have the facilities specified in the Bill. The location is grouped as rural, urban, metro and notified/inaccessible areas, with provisions made for practical limitations. The description is along the lines of ownership (central, state, ESI, Ministries e.g., Railways, police, defence etc., and private) as well as systems of medicine catered for. Further all this information is available in public domain. Committees will be appointed with representation across the board to certify, register and adjudicate in case of difficulties. These are already in the process of formulation. Annexure 8 of the Bill was particularly reassuring because it addressed the issue of patients’ rights and responsibilities. The latter stipulates that the patient shall follow all instructions, pay the hospitals agreed fees on time, respect the dignity of doctors and other hospital staff, and never resort to violence. The section on informed consent would have done well to adopt the “SOP on Informed Consent” drafted by the Institute of Medicine and Law in view of the significant changes that have developed in the issues of consent and negligence.
Whilst moral principles are expressed in absolutes, health care policy is an endless reconciliation of the ends and the means. However, this must always be against a background of the patients’ interests. The altruistic desire of dedicated professionals to use expensive technology to genuinely help detect and treat disease, must accommodate the freedom of an entrepreneur to pursue legitimate profit. These are hard political, economic and medical decisions based on the needs of the patients.
Healthcare must shift from the current paternalistic mode to the partnership mode where the patients’ interests reign supreme. Without that chaos will continue to reign.
(The author is a founder member of VHAG)
