Don't back a failed model

The Niti Aayog has brought out draft guidelines for Public Private Partnership (PPP) for non-communicable diseases (NCD) in district hospitals to “ensure healthy lives and promote well-being for all ages.” It hopes to reduce by a third premature mortality from NCDs through prevention and treatment, and promote mental health and well-being by 2030.

The draft also talks about the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS), launched in October 2010 and aimed at institutionalising the response to NCDs and supplementing state effort through setting up of NCD cells at the state level and integrating it with the National Health Mission (NHM) framework. It states that attendance at NCD clinics have witnessed a 118% year-on-year increase. State NCD cells have been set up in 36 states and Union territories, with 322 districts having district NCD cells and 318 having NCD clinics.

The document then goes on to talk about systemic gaps in the programme, such as the constrained fiscal space that impacts states’ ability to provide increased allocation for NCDs, large infrastructure gaps, especially in rural areas, and significant gaps in human resources, especially at the level of specialists, all of which have led to people having to seek healthcare in the private sector.

The section on addressing these challenges then goes on to state that the Government of India is exploring options to leverage the strengths of the private health sector to “infuse greater efficiencies and resources and to bring in innovative options of engaging with the private sector to augment the gap in the operational capacity” to deliver NCD services.

The World Bank has apparently been appointed to provide technical assistance for development of the PPP model and a draft model concession agreement for engaging with the private sector, based on pilots where select districts in one or two states would be bid for a lease of 30 years to a single private partner or a consortium of private partners to provide NCD services.

It is important to pause at this point and revisit this apparently innocuous framework. The first point to be considered is that PPP pilots have been tried in several states, with Karnataka being the laboratory for all kinds of pilots.

The PPP for primary healthcare, the Arogya Bandhu scheme, was revoked and scrapped by the state government in January 2016 following a series of complaints of non-compliance with rules, misuse of funds, lack of accountability, poor availability of qualified human resources and failure to provide quality service to patients by the NGOs running these primary health centres.

The PPP for tertiary care, the Rajiv Gandhi Super Speciality Hospital, was also rolled out in Karnataka, in Raichur, as a tie-up between the state government and Apollo hospitals, with the government providing 73 acres land, the hospital building, staff quarters, roads, power and water and financial aid of Rs 60 crore. Following an evaluation by the state government in April 2011, it was found that there was poor governance, accountability and grievance redressal mechanisms in the hospital, with rapidly declining access to services for below poverty line (BPL) patients. The contract was terminated in May 2012 and hospital equipment to the tune of Rs 37 lakh was seized by the Principal District and Sessions Court for unpaid dues. These two models have been highlighted as “successful” models of PPP!

The second point to be noted is that the World Bank has been at the forefront of pushing for structural adjustment programmes, user fees, PPPs, and generally opening up the market for the social sector. When some of these models promoted by the World Bank have failed and caused damage to comprehensive access to healthcare and derailed public systems, has this body been held to account?

Is there even a system in place to hold the World bank to account for the disastrous policies that it has introduced into different countries? Why is this body that has promoted policies that have not served large sections of the country, particularly the vulnerable, still continuing to provide ‘technical assistance’ to push for those same models?

Not a private issue

Thirdly, why aren’t the gains and successes of the NPCDCS, as claimed by Niti Aayog, being strengthened instead of being thrown away by handing over the entire structure to the private sector? Is it due to lack of political will of bodies like Niti Aayog? Why is the private sector being promoted as the panacea for healthcare problems when it has been known to hold the government responsible for all private sector rights, privileges and entitlements while being completely resistant to grievance redressal mechanisms for patients and any form of government regulation? In Karnataka, private medical establishments have refused to implement the Vajpayee Arogyashree Scheme (VAS) until payment packages are increased.

Already constrained public healthcare staff are being used for administrative purposes and to mobilise patients towards the very centralised private healthcare facilities, where patients have been documented to spend anywhere between Rs 10,000 and Rs 1 lakh. This new scheme of the Niti Aayog to handover functional district hospitals to private players will only aggravate the problems that are already known and documented. How can public hospitals be handed over to the private sector? Where is the evidence that the private sector has allowed itself to be regulated or be held accountable?

It is important that the government accepts that many of these PPP models in healthcare have failed, and not promote them as successful models despite all the evidence pointing to the opposite. The government would do well to look at healthcare as an inviolable human right that requires comprehensive preventive, promotive, curative and rehabilitative strategies, rather than just pandering to the World bank and to the corporates.

(The writer is a public health researcher)