Kerala’s Public Health Sector a Divided House Following a Legislation

The much-awaited Kerala Public Health Bill 2023 is just one step away from becoming a reality.?

Billed as a game-changer, it consolidated and unified the existing laws relating to public health in the state. The bill that envisions ‘proactive and reactive’ measures in matters that affect public health also gives priority in preventing and controlling emerging diseases and existing communicable and non-communicable diseases.?

But on the flip side, the bill has resulted in pushing the state’s public health sector to a divided house as it opened a new war front between modern medicine and the AYUSH sector.?

The bone of contention between them is because of some provisions and vagueness in the bill.

?On one side of the conflict is the state chapter of the Indian Medical Association (IMA) representing modern medicine. Opposite to it is AYUSH Aikyavedi, a unified platform that brings together Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy.?

As IMA sees red in the government’s ‘last-minute changes’ in the bill to include the AYUSH sector, the latter says that their demands were not fully met.?

With AYUSH Aikyavedi planning to take up the matter with the state government, sparks could fly between them and IMA.?

It was on last Tuesday (March 21) that the Kerala Public Health Bill 2023 was passed in the eighth session of the 15th Kerala Legislative Assembly (KLA). However, the bill was passed without any discussion as the CPI(M) led government decided to cut short the legislative business and to adjourn indefinitely following protests by the Opposition.?

The bill which now awaits the Governor’s assent to become an act will supersede the two acts – Madras Public Health Act 1939 and Travancore-Cochin Public Health Act 1955 – which now govern the public health sector of the state.?

?A first draft dominated by modern medicine and the suspense?

?What irked the AYUSH sector most was a provision that mandated only a registered medical practitioner of modern medicine to certify a person as free from communicable disease or notifiable communicable disease.?

Another one was the constitution of the State Public Health Authority (SPHA), the District Public Health Authorities (DPHA), and Local Public Health Authorities (LPHA).?

?These were included in the first draft of the bill.?

?As per it, SPHA, DPHA, and LPH will be headed by officials representing modern medicine and it shall have the power to issue directions on public health matters, to any department of the government.?

While the AYUSH sector questioned the legal validity of the issuance of a certificate only by a registered medical practitioner of modern medicine, it objected to the name ‘Authority’ as it sounds authoritative.?

They instead suggested a ‘Committee’ comprising representatives of AYUSH, other departments, and people’s representatives.?

Eventually, these two provisions got corrected in the final draft after the matter was taken up with the government.?

Regarding the issuance of the certificate, it was amended that ‘a registered medical practitioner’ –which means that irrespective of which medical system one represents –could certify a person as free from communicable disease or notifiable communicable disease.?

In the case of the formation of SPHA, DPHA, and LPHA, it was amended to State Public Health Committee (SPHC), District Public Health Committees (DPHC), and Local Public Health Committees (LPHC).?

“The suspense was there regarding the very inclusion of AYUSH in these committees and giving the right to issue the certificate. It was a meeting attended by the chief minister, KLA secretary MM Basheer, Parliamentary Affairs Minister K Radhakrishnan, Mathew T Thomas MLA, and others which finally decided to include AYUSH,” said a source.?

It is learned that the meeting considered the opinion that the bill without AYUSH representation might become ultra vires as it will come in conflict with the Centre legislation – National Commission for Indian System of Medicine (NCISM) Act 2020.?

Section 34 (c) of this act which mentions the rights of persons to practice guarantees the right to a duly qualified medical practitioner to sign or authenticate a medical or fitness certificate or any other certificate required by any law.?

‘A result of constant intervention’?

?As the AYUSH sector celebrates the recognition it found in the bill, Dr Sadath Dinakar, chairman, legal committee of the Ayurveda Medical Association of India (AMAI), said that they had to earn it.?

“It is an irony that even though the AYUSH is a recognized system we had to knock at the door of the government for including us also in the public health bill. We earned that recognition. But we are not at all satisfied,” said Dr Sadath.?

According to him, AMAI on its behalf had sent representations to the concerned reminding them that overlooking AYUSH might have repercussions.?

“The first draft of the bill is nothing but a blatant violation of the existing Union laws. It violated the provisions of the NCISM Act and the Indian Medicine Central Council Act 1970. If the government had not considered the AYUSH system, it would have resulted in a legal battle,” said Sadath.?

?'The fight is not over yet’?

?According to Dr Abhil Mohan, treasurer of AYUSH Aikyavedi, public health is not the prerogative of modern medicine and it is disheartening that the AYUSH sector had to fight for even consideration.?

“To discriminate between practitioners of modern medicine and AYUSH is unjust. Ours is also a recognized system of medicine. But unfortunately, when the first draft of this bill came out the AYUSH sector got cold shoulders,” said Dr Abhil.

He also added that it was at this juncture that a decision was made to form AYUSH Aikyavedi to bring the sector’s concerns and suggestions to the government’s notice and to coordinate the fight for ‘acceptance’.?

?“Thanks to the common platform (AYUSH Aikyavedi) some changes indeed happened. In the final draft, the AYUSH sector got acceptance. But the fight is far from over. Some obscurity is still there regarding AYUSH’s role in protecting public health. We want clarity on the same,” said Dr Abhil, who is also the general secretary of the Siddha Medical Association of India.?

Some of the concerns/unclearnesses that still exist with the bill as pointed out by the AYUSH sector include: making the Director of Health Services the State Public Health Officer and vested with a lot of powers; absence of the role, duties, and power of the SPHC, DPHC, and LPHC; not appointing a protocol committee for framing the guidelines for treating various ailments by including representatives from the AYUSH sector and others.?

Earlier, five of the 15-member Assembly Select Committee, which examined the bill in detail and hold discussions with experts, various stakeholders, and citizens before finalizing it, had undersigned a dissenting note. In it, the members expressed concern over giving excessive powers to the Local Public Health Officer and overlooking other systems of medicine in the preparation of treatment protocols.?

The Aikyavedi is now in the process of drafting representations to chief minister Pinarayi Vijayan and health minister Veena George for bringing clarity to these aspects and defining the role of the AYUSH sector in protecting the health of the people.?

?‘AYUSH System Intelligently Excluded’?

?At the same time, IMA stated that AYUSH can’t be considered part of the public health system.?

Said Dr Sulphi N, state president, IMA, “There is a campaign among AYUSH practitioners that they got the right to certify a person as free from communicable disease or notifiable communicable disease. But that is not the truth. They were intelligently excluded.”?

He further added, “It has clearly been stated that a registered medical practitioner who treats a person for communicable or notifiable communicable diseases could certify him/her as free from the same after considering examinations including lab tests. There are no tests in Ayurveda or Homoeopathy. Also, these parallel system of medicine lacks treatment for communicable diseases like plague and rabies and notifiable diseases like Japanese Encephalitis.”?

He also alleged that the state government had to yield to a certain extent due to the bullying attempts of AYUSH practitioners at various platforms including at the meetings convened by the Assembly Select Committee.?

?Journey of the Bill?

The demand for a unified public health bill was there for some time now. The first step towards making this demand a reality happened on October 4, 2021, as the first draft of the bill got published in the gazette. Then on October 27, 2021, the bill was presented in the Assembly. On the same day, it was sent for the consideration of the Select Committee. The committee then held six meetings in Thiruvananthapuram, Ernakulam, Kozhikode, and Kottayam districts for eliciting suggestions and opinions. It was on March 13, 2023, that the final draft got approved.?

The bill touches upon subjects including emerging diseases related to climate change, zoonoses, lifestyle diseases, antimicrobial resistance, safe food, water and sanitation, and others. Ensuring the one-health approach in all aspects, it also gives priority to senior citizens, women, children, and migrant laborers.?

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