Kasaragod: The Indian Medical Association (IMA) will stage a sit-in protest before all 14 District Medical Offices in Kerala on February 13, intensifying its demand that small clinics and hospitals be exempted from the Kerala Clinical Establishments (Registration and Regulation) Act, 2018 -- a law enacted exclusively for them.

The protest comes despite a Division Bench of the High Court on November 26, 2025, dismissing challenges to the Act and directing all clinical establishments in the state to register within 30 days and prominently display their registration certificates.

The IMA said it was opposed to the indiscriminate implementation of the law, which it believed would throttle small and medium healthcare institutions that keep healthcare affordable for ordinary people.

'Protect small hospitals'
The primary demand is to exclude hospitals with up to 15 beds from the purview of the Act. According to IMA leaders, such small establishments operate on thin margins and serve semi-urban and rural populations at comparatively low cost. “In states such as Haryana, hospitals with up to 50 beds are exempted from the Act,” said Dr B Narayana Naik, IMA Central Working Committee member.

The association argues that small hospitals form the backbone of Kerala’s much-celebrated public healthcare model by keeping treatment affordable. "Small hospitals are essential to keep treatment affordable at a time when foreign investors are swallowing up the healthcare sector in India," said Dr Janardhana Naik C H, chairman of IMA Kasaragod. Over 800 small hospitals and clinics have shut down in Keala in the past decade, he said.

Consultation clinics
Another contentious issue is the status of consultation-only clinics. Currently exempt from the Act, such clinics would come under mandatory registration if they provide even basic diagnostic services, said Dr Narayana Naik. “Without basic lab tests, even something as simple as blood sugar, how are doctors supposed to make a prognosis? But the moment you install a basic lab facility, you are brought under the Act,” he said.

The IMA wants the government to allow such consultation-only clinics to set up basic lab and diagnostic centres and patient-monitoring facilities without bringing them under the purview of the Act.

Transparency vs practicality
The Kerala Clinical Establishments Act requires establishments to publish fee rates and package rates for treatments. The High Court single bench and the division bench upheld this provision, emphasising transparency and patient rights.

However, the Kerala Hospital Association and the IMA argued before the court that the requirement is vague and impractical as treatments often involve multiple procedures that vary from patient to patient. But the court ruled that hospitals should publish the baseline price, with a rider saying "unforeseen complications or additional procedures shall be itemised and billed". "That will leave room for patients to argue with us if we exceed the baseline price," said Dr Narayana Naik.

He said registration of clinics would send the operational cost up, as the government has made hiring of BSc nurses mandatory. "For a BSc nurse, we have to pay at least Rs 40,000. And if we hire general nurses, the government can cite that as a reason and cancel our registration," said the IMA central working committee member.

To be sure, the government has not put out such a hiring regulation. Moreover, in the high court, the IMA and private hospitals argued that revealing their staff pattern and their qualifications would open them to predatory poaching by rival hospitals. The Division Bench rejected these concerns, stating that issues like potential “poaching” of staff or RTI disclosures cannot override patient safety and transparency.

The Division Bench, while rejecting their petitions, laid down clear guidelines for clinical establishments in line with the law, which included stabilising emergency patients within their capacity, ensuring safe transfer to higher centres when required, and not denying life-saving treatment over non-payment of advance. It also directed all establishments to file compliance undertakings within 30 days. Dr Naik said a small hospital with 15 beds or fewer would not have the resources to ensure "safe transfer" of emergency patients. "That's why we are asking them to be exempted from the Act."

As IMA members prepare for another round of protest, the law -- enacted eight years ago as a welfare measure -- remains only on paper.