End of pub­lic health­care?

In­dia is ea­gerly hand­ing over its pub­lic health fa­cil­i­ties in towns and vil­lages to pri­vate play­ers. Is this the end of pub­lic health­care?


In­dia is rapidly pri­vatis­ing hos­pi­tals and clin­ics in towns and vil­lages

HOW DO gov­ern­ments push for pri­vati­sa­tion of pub­lic prop­erty? The the­ory goes that first they ne­glect and starve the sys­tem of funds. When fail­ing ser­vices spoil pub­lic per­cep­tion, they ac­cuse the institution of not work­ing prop­erly. The so­lu­tion they sug­gest is to give the institution to pri­vate play­ers. Here is a clas­sic ex­am­ple of this the­ory. niti Aayog, the gov­ern­ment think-tank, has sug­gested run­ning dis­trict hos­pi­tals on the pub­lic-pri­vate part­ner­ship (ppp) model be­cause “the sys­tem con­tin­ues to re­main con­strained with a set of sys­temic is­sues”. It has sent all states a draft copy of the model con­ces­sion agree­ment and guide­lines, ask­ing for their com­ments.

Down To Earth has the draft copy of the agree­ment and guide­lines with the let­ter sent to the chief sec­re­tary of Ch­hat­tis­garh, Vivek Kumar Dhand, on June 9. It gives a glimpse of the gov­ern­ment plan. niti Aayog has sug­gested that all states will al­lot part of state-run hos­pi­tals’ space to pri­vate play­ers on a 30-year lease for set­ting up fa­cil­i­ties with 50 or 100 beds. The pri­vate player that wins the bid will chip in with the cap­i­tal cost, while the hos­pi­tal au­thor­i­ties will pro­vide free space, prefer­ably at least half of it within the ex­ist­ing struc­ture of the hos­pi­tals.

The draft sug­gests a few cri­te­ria for the se­lec­tion of hos­pi­tals, in­clud­ing the ones in Tier 2 or Tier 3 cities. The dis­trict hos­pi­tal should have an av­er­age per day opd of 1,000 pa­tients or more in the past two years. Two types of pa­tients may visit the fa­cil­ity un­der pri­vate man­age­ment: those who are re­ferred by the gov­ern­ment and paid through gov­ern­ment in­sur­ance schemes; and those who pay from their pocket. Thus, the pri­vate play­ers will be paid for their ser­vices.

niti Aayog says it is in­volv­ing pri­vate play­ers for the sake of re­duc­ing the bur­den of non-com­mu­ni­ca­ble dis­eases (ncds), as the ppp ser­vices will be cre­ated specif­i­cally for such dis­eases. Its logic is: “De­spite con­certed ef­forts at the na­tional and state lev­els over the last few years in es­tab­lish­ing the

ncd ser­vice de­liv­ery net­work, the sys­tem con­tin­ues to re­main con­strained with a set of sys­temic is­sues.” It says the key chal­lenge is find­ing money to in­crease al­lo­ca­tions for ncds, build in­fras­truc­ture in ru­ral ar­eas and hire spe­cial­ists.

Th­ese are the same con­cerns peo­ple have been rais­ing for at least 20 years. Ravi Dug­gal, In­dia co­or­di­na­tor of the ad­vo­cacy group, In­ter­na­tional Bud­get Part­ner­ship, ex­plains this ne­glect with facts. He says the 12th five-year plan had pro­posed `2,68,551 crore on health and fam­ily wel­fare but the fi­nal al­lo­ca­tion was dras­ti­cally re­duced to `1,25,117 crore or a mere 46.6 per cent of the orig­i­nal planned al­lo­ca­tion. Par­lia­men­tary Stand­ing Com­mit­tee on Health and Fam­ily Wel­fare had con­cluded in its re­port last year that if the en­tire al­lo­ca­tion of the 12th Plan had been made avail­able to the Min­istry of Health and Fam­ily Wel­fare, it would have ef­fec­tively strength­ened dis­trict health sys­tems. Dug­gal gives an­other ex­am­ple of fund de­pri­va­tion.

Now, the gov­ern­ment is say­ing that 72 per cent of the pop­u­la­tion in ru­ral ar­eas and 79 per cent in ur­ban ar­eas seek health­care in the pri­vate sec­tor (see: ‘Pri­vate takeover’, p24).

States on pri­vati­sa­tion spree

Some states are al­ready flirt­ing with the ppp model. Ra­jasthan is one of them. The state has lately been on a spree to hand over pri­mary health cen­tres (phcs) to pri­vate agen­cies un­der its “Run a phc” scheme, says Ch­haya Pachauli, se­nior pro­gramme co­or­di­na­tor at Prayas, a non­profit in Ra­jasthan.

In 2015, the gov­ern­ment is­sued ten­ders for phcs in ru­ral ar­eas but found very few tak­ers be­cause there is no big scope for profit, says Pachauli. Through an rti ap­pli­ca­tion, Prayas learnt in Jan­uary this

year that 41 phcs in the state are be­ing run by pri­vate play­ers. Of th­ese, 19 phcs were given to Wish Foun­da­tion. Here the story gets com­pli­cated. Be­fore invit­ing the ten­der for ru­ral phcs, the state had given 30 phcs to Wish Foun­da­tion, which had com­mit­ted to not take any money from the gov­ern­ment.

Later, the gov­ern­ment de­cided to issue ten­der for 213 phcs, where the gov­ern­ment of­fered to pay money to pri­vate play­ers. Wish Foun­da­tion re­quested the gov­ern­ment to in­clude the 30 phcs it was run­ning in the list of those go­ing for the bid­ding. At that time the state gov­ern­ment re­fused to do so. But the fi­nal re­sults show that 19 hos­pi­tals run by the foun­da­tion have been in­cluded. Pachauli says this in­di­cates cor­rup­tion in the sys­tem. Ra­jasthan has now in­vited ten­ders for 50 phcs in ur­ban ar­eas.

This is the same state that had a flour­ish­ing model of pro­vid­ing free treat­ment to peo­ple in the pre­vi­ous gov­ern­ment’s regime. Un­der schemes like Mukhya­mantri Nishulk Dawa Yo­jna (mndy) and Mukhya­mantri Nishulk Jaanch Yo­jana (mnjy), pa­tients in gov­ern­ment hos­pi­tals were en­sured free di­ag­nos­tics and medicine.

Pachauli says mndy and mnjy were at­tract­ing more pa­tients to seek health­care from pub­lic health fa­cil­i­ties. But rather than strength­en­ing the pub­lic health in­fras­truc­ture to cater to the in­creas­ing de­mand, Va­sund­hara Raje, soon af­ter as­sum­ing the of­fice of the chief min­is­ter in 2014, launched an in­sur­ance scheme. Bhamashah Swasthya Bima Yo­jana re­lies on pri­vate providers to de­liver health­care ser­vices.This was done de­spite the fact proven time and again that while health in­sur­ance schemes may in­crease chances of treat­ment, they do lit­tle in terms of re­duc­ing out-of-pocket ex­pen­di­ture.

Mad­hya Pradesh is an­other ex­am­ple where the state gov­ern­ment has been push­ing for the pri­vati­sa­tion of phcs. Un­der the garb of re­duc­ing in­fant and ma­ter­nal mor­tal­ity, the state gave the Ali­ra­jpur dis­trict hos­pi­tal to Deepak Foun­da­tion, a Vado­dara-based Trust, with­out the ten­der­ing process. Amulya Nidhi, an In­dore-based health ac­tivist, says the state gov­ern­ment had a plan to ex­tend this model to 27 dis­tricts. How­ever, it with­drew the plan af­ter a pe­ti­tion was filed in Ja­balpur High Court.

But the gov­ern­ment has not given up on pri­vati­sa­tion. On June 3, 2016, it signed an agree­ment with Tata Trust un­der Trans­form Ru­ral In­dia pro­gramme. The trust will work in six dis­tricts to im­prove health and nutri­tion. The same trust will be en­gaged in cancer treat­ment in Uj­jain. The gov­ern­ment has also pro­posed a help desk called Janani Shishu Su­rak­sha Karyakram in a num­ber of dis­tricts to be run on a ppp model.

No lessons learnt from past

Kar­nataka shows what hap­pens when phcs are handed over to pri­vate play­ers. Un­der the Ar­o­gya Bandhu scheme, the state gov­ern­ment was to de­velop part­ner­ship with pri­vate play­ers for run­ning 52 phcs. It signed an agree­ment with Karuna Trust in 2006 to man­age 27 phcs. The gov­ern­ment was to pro­vide fi­nan­cial as­sis­tance and the pri­vate play­ers were to pro­vide ser­vices. But af­ter com­plains about the qual­ity of ser­vice and non-com­pli­ance of rules, the gov­ern­ment can­celled the agree­ment.

Com­plaints made against Karuna Trust were quite se­ri­ous. Sylvia Karpagam, a health ex­pert in Kar­nataka who is writ­ing a pa­per the pri­vati­sa­tion of health­care, gives a few ex­am­ples. In De­cem­ber 2010, 286 in­mates of Beg­gars’ Home in Ben­galuru died at the Beg­gar’s colony phc run by Karuna Trust. Sev­eral bod­ies dis­ap­peared. On Septem­ber 16, 2014, the Depart­ment of Health and Fam­ily Wel­fare held Karuna Trust re­spon­si­ble for the spread of dengue in some of the vil­lages cov­ered by the phc in Chan­dra­banda vil­lage of Raichur dis­trict. Vis­it­ing ex­perts to phcs found that doc­tors were not com­ing on time.

The In­sti­tute of Health Man­age­ment and Re­search in Ben­galuru had also con­cluded in its study that there is not much dif­fer­ence in the ser­vices pro­vided by pri­vate play­ers and the gov­ern­ment in run­ning phcs. While with­draw­ing the agree­ment with Karuna Trust, Kar­nataka’s health min­is­ter U T Khader had also said: “On eval­u­a­tion, we have also found that there is no ac­count­abil­ity, and some of the ngos do not even have the re­quired num­ber of doc­tors and paramed­i­cal staff. The ngos have em­ployed ayush doc­tors and un­trained nurses in some phcs. Why should the gov­ern­ment pay them for such sub­stan­dard ser­vices?”

It seems the min­is­ter’s com­ment and Kar­nataka’s ex­pe­ri­ence have not made the niti Aayog and the other states flirt­ing with ppp any wiser.

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