SOCIAL JUSTICE CURRENT AFFAIRS 2017 PUBLIC PRIVATE PARTNERSHIP (PPP) IN HEALTH Financial resources of a nation must be best directed towards interventions that have an inherent potential to maximise social benefits. In this regard, access to quality health care to the population is a prerequisite to creating a just and equitable society. India has made important progress in health sector. Average life expectancy at birth has risen to 65 years for male and female combined which is twice the time at late 1940 s. India is also free from polio. However large section of population doesn t have reliable and affordable access to good quality healthcare. India s healthcare system is far behind those of other emerging economic powers. India s healthcare system is on the road of increasing partnerships between Government public-health-oriented hospitals and private entities. A direction initiated with the World Health Organisation s Invest in Health move in the 1990s and pushed by both the World Bank and the IMF. NITI Aayog is driving the agenda of PPP in India. PROBLEMS OF PUBLIC HEALTH FUNDING IN INDIA LOW SPENDING: India contributes to 21% of the global disease burden, but has one of the lowest public health spending in the world. India spends only 1.3% of GDP on public health. This is the lowest among the BRICS nations. SPECIAL PROGRAMMES FOR RULING ELITE: One reason for low spending on health is that the governments and their employees are shielded from policies meant for the common people. Countries that have done well in providing quality care have one system for all. For example, the Central Government Health Scheme (CGHS) has existed for decades and has been emulated by several states, which have floated similar schemes that discriminate between those who are employed by the state and those who are not. A grave impact of the CGHS and similar plans on public health is that India s ruling elite do not have an incentive to improve the system as they would never use it. UNPLANNED SPENDING: Non-communicable diseases account for 60 per cent of the premature mortality in India and cardiovascular diseases, pulmonary diseases, cancer, as well as hypertension, diabetes and stroke are among the leading killers, accounting for four of the top five causes of death, according to the Institute for Health Metrics and Evaluation. Yet the allocation in the Union budget to meet the growing need for NCD care is barely 3 per cent of the total allocation of Rs 20,000 crore under the National Health Mission (NHM). Take NEO IAS 0484-3190310, 9446331522, 9446334122 Page 1
cancer as an example: India has 750 radiotherapy units against a requirement of 1,300. MISMANAGEMENT: Many Government run institutions are ill-equipped. In the prestigious AIIMS at New Delhi, we have 1.33 lakh cancer patients seeking care, of which only 36,000 get admitted with the number of beds available for chemotherapy being a mere 36. NEED OF PUBLIC SECTOR The private sector plays a minimal role in preventive health care. Most Indians access the generally expensive private sector for curative care, even for minor ailments. Given the large population, low per-capita income and a high burden of disease in India, the country needs high-quality comprehensive primary care that is free or easily affordable at the point of service and impartially accessible to all. NEED FOR THE INVOLVEMENT OF PRIVATE SECTOR IN THE HEALTHCARE SECTOR Private sector continues to grow at 15 per cent per annum, accounting for 58 per cent of rural and 68 per cent of urban in-patient care with 80-90 per cent of health facilities and a five-fold higher doctor density. SIGNIFICANCE OF A PRIVATISED SYSTEM INDIVIDUALISED CARE: Individualised care is obviously easier in private than in government institutions. One can choose both the treating doctor and the time and place of treatment. In certain conditions the patient may want to choose the method of treatment as well. This is especially true for surgery where more than once option is available, such as between endoscopic and open removal of a gall bladder. It can be even more critical when there could be a choice of a life support device such as a pace maker. BETTER NURSING AND ALLIED SERVICES: A privatised system can also provide better nursing and allied services. It can provide better facilities for attendants and other care-givers. Patients and their relatives are not pushed around, neglected and ignored. Such care may also provide patients with a choice of convenient timings, treatments and costs, though these factors can be limited in both private and public sector settings. ADDRESSES ABSENTEEISM OF DOCTORS: After decades of effort at strengthening our health system, we are still grappling with the rampant absenteeism of doctors ranging from 28 per cent to 68 per cent in different states. Community Health Centres report a 65 per cent vacancy rate of specialists since governments are simply unable to attract and retain talent. Even where we are able to get them to attend to their jobs, the effort put in by qualified doctors in NEO IAS 0484-3190310, 9446331522, 9446334122 Page 2
government facilities is far worse than their private counterparts. Privatisation can address this issue. REDUCE OVERLOAD: Our tertiary facilities are disproportionately overloaded. The NSSO s 71st round registered a decline in the share of in-patient services provided by government-owned facilities in 12 out of 20 major states in rural areas and in 17 out of 21 states in urban area. ACCESS TO ADVANCED TECHNOLOGY: Private sector is much advanced in health sector in India in terms of equipment, accessibility, quality of service. HUMAN RESOURCE: Tier 2 and 3 cities lack number of Doctors, Nurses proportion in comparison to population. This move can attract urban medical professionals to pursue their career in these cities. BETTER GOVERNANCE, MORE INVESTMENTS: Public funds are in shortage to administer government hospitals coupled with corruption, failure of timely service, etc. THE PRICE OF PRIVATISATION MONOPOLY: Privatisation may lead to steep hike in health expenditures, attributable to the increased costs of medical consultations, drugs and devices, medical tests and hospitalisation. Private medical practice is a profession, not just a public service. It promotes corporatisation FOCUS ON RECOVERING THE INITIAL INVESTMENT: Because of the pressure to make a profit, many private doctors, hospitals and diagnostic centres promote uncalled-for investigations and treatment in order to recover their initial investment. So, services with limited value will be popularised and promoted to many people whether or not they need it. UNHEALTHY COMPETITION: Privatisation may also encourage unhealthy competition among the groups involved, since the objective is not only to earn, but to earn more than others. RELATIVE NEGLECT: Privatisation leads to the relative neglect of problems from which there is little to earn. Everyone including the state is interested in setting up commercially viable units. National preventive programmes get neglected. REGIONAL INEQUALITY WITH PRIVATE SECTORS concentrating in well to do districts. HIGH OUT-OF-POCKET EXPENDITURES DOES NOT GUARANTEE CURE: Even high outof-pocket expenditures may not guarantee quality of care. For example, in the case of tuberculosis, a number of private practitioners and laboratories continue to use inappropriate diagnostic tests and prescribe improper drug regimens, which contribute to the emergence of drug resistance without curing the patient. NEO IAS 0484-3190310, 9446331522, 9446334122 Page 3
UNDUE STRESS ON PROCEDURE-ORIENTED MEDICINE: Well-considered, comprehensive advice is bypassed for a computerised laboratory test, resulting in the loss of the human touch. PUSH FOR ASSOCIATION WITH THE PRIVATE SECTOR Two recent developments related to public health in India hold the prospect of changing the nature of service provision for the people. Both lean heavily on the private sector in an effort to improve the deplorable state of healthcare services for India s 1.3 billion people. DELHI GOVERNMENT POLICY: A new policy by the Delhi government was announced which said that the government would pay for surgeries of private citizens conducted at private hospitals. These surgeries would be ones that the government would not be able to conduct expeditiously at its own facilities. The Delhi government s effort is a giant leap in establishing distributive justice. However, the Delhi government needs to be mindful of the fact that implementation holds the key to universalization of such schemes. POSITIVES Delhi has a population of more than 16 million and its health infrastructure is grossly insufficient to cater to the needs of all its residents The Delhi government s effort is a giant leap in establishing distributive justice. The scheme is a novelty for the common man but has a precedent in several government schemes for employees which use public funds to provide private healthcare. For example, the Central Government Health NEO IAS 0484-3190310, 9446331522, 9446334122 Page 4
Scheme (CGHS) has existed for decades and has been emulated by several states, which have floated similar schemes that discriminate between those who are employed by the state and those who are not. This is a violation of the principles of justice. CONCERNS But private healthcare in India usually offers quality service but is often expensive and largely unregulated. The national health policy notes growing incidences of catastrophic expenditure due to healthcare costs, which are presently estimated to be one of the major contributors to poverty. NITI AAYOG PROPOSAL: NITI Aayog has released a report on the public-private partnership (PPP) model in healthcare a plan to effectively privatise district hospitals in Tier-I and Tier-II towns. It has developed a model concessionaire agreement for provision of healthcare services for cardiac and pulmonary (lung) diseases and cancers. The PPP model will work alongside the public health system and will be chargeable. Public facilities in district hospitals would be outsourced to private providers. They would be free to charge full treatment costs from patients not covered by government schemes (such as the Rashtriya Swasthya Bima Yojana) and the providers would be reimbursed by the government for treating patients referred by the government. NEO IAS 0484-3190310, 9446331522, 9446334122 Page 5
CRITICALLY ANALYSE NITI AAYOG S RECENT PUSH FOR PRIVATISING DISTRICT HOSPITALS IN TIER 2 AND 3 CITIES NO PRECEDENCE: The proposed model consists of leasing out for 30 years a portion of the hospital to a private company to provide treatment for the three diseases cardiology, cancer and pulmonology that account for 35 per cent of mortality in India. It s a strange hybrid that has no precedent anywhere in the world. AGAINST NATIONAL HEALTH POLICY: It goes against the spirit of India s national health policy, which seeks to provide free, comprehensive primary healthcare services for all aspects of reproductive, maternal, child and adolescent health and for the most prevalent communicable, non-communicable and occupational diseases in the population. The policy recommends strategic purchase of secondary and tertiary care services as a short-term measure, but not services people would pay for. PATIENTS ARE NOT STAKEHOLDERS: The PPP guidelines for district hospitals stipulate that the Working Groups constituted by Niti Aayog should involve the participation of private healthcare providers, the Health Ministry, an expert group of healthcare providers, and the Confederation of Indian Industry. Evidently, patients were not considered stakeholders who needed to be represented. LIMITED SUCCESS: The management of PHCs is handed over to the private sector, citing the public health system s failure in providing quality care in remote areas. However, this has not worked out in Bihar and Rajasthan as the private sector has tended to take over PHCs in locations other than where they were intended. LOW PENETRATION OF PUBLIC-FUNDED INSURANCE: The proposal implies that most patients would have to pay for care even in public facilities. The promise that patients covered by government health insurance schemes would access care free of cost needs to be seen in the context of recent surveys which show that just 12-13% of people are covered by public-funded insurance. PROBLEMS OF GOVERNMENT SPONSORED INSURENCE SCHEMES: The NITI Aayog suggested the need for a universal health insurance scheme. However, insurance schemes have their limitations, such as the denial of certain services for many categories of illnesses and oversupply of some services in the private sector. For example, the government launched Rashtriya Swasthya Bima Yojana (RSBY) scheme to provide health insurance for Below Poverty Line (BPL) families. The scheme provided various incentives for private insurance companies and hospitals and close to 3.6 crore Indians were insured under RSBY. However, RSBY has its shortcomings such as the missing components of outpatient care as part of the scheme. There is also the problem of exclusion. There are BPL families who are entitled to the scheme but do not NEO IAS 0484-3190310, 9446331522, 9446334122 Page 6
figure on the list. And then there is the inevitable exclusion of a large number of people who are only marginally above the poverty line. WORSEN INEQUITY: The proposal does not further the idea of justice. The proposal is designed to further worsen inequity in access to healthcare services. Private providers will concentrate on better-off districts, leaving the poor and remote districts for the public sector to manage. This will further weaken the ability of public hospitals to attract and retain trained doctors and other health workers. UNETHICAL PRACTICES: The scheme will expose thousands of patients to unethical practices by private providers, compromises in quality and rationality of services and additional top-up services. A specific section in the document on risk management is primarily concerned about risks of private providers, with very little about robust mechanisms to protect patients from unethical practices. INHERENT PROBLEMS OF PRIVATE: Outsourcing of hospital care to private providers inevitably becomes increasingly unsustainable over time as they ratchet up demands on reimbursements and fees. While a Public Health Centre (PHC) cannot deny treatment to anyone, a private partner can. RELUCTANCE OF GOVERNMENT FUNDING: The proposal to hive off hospital care to the private sector is justified by the argument that public services are not financed adequately and face an acute shortage of trained human resources. The simple remedy could be to significantly enhance investment in public healthcare services, including in the training of health workers. The government s singular resistance to follow such a path is linked to its ideological moorings, which find virtue in private enterprise and view public services as inherently NEO IAS 0484-3190310, 9446331522, 9446334122 Page 7
inefficient. This scepticism regarding public services needs to be tempered by the experience that success stories of public health, in diverse settings such as the U.K., France, Cuba, Thailand and Sri Lanka, are all related to public systems. PROBLEMS IN THE POLICY: In district hospitals, partnership with the private sector is only possible if the hospital has 1,000 patients attending their out-patient departments. The onus of ensuring that PHCs and CHCs (community healthcare centres) refer patients to the private partner is on the government. A common point between the NITI Aayog proposal and the national health policy is that both support government schemes which provide preferential care to government employees in the present and future. India s privileged elite believe they deserve quality care before others. MISMANAGED PUBLIC SECTOR: It is in this context that the deaths of children at Gorakhpur s BRD hospital need to be seen. The deaths are primarily due to corruption in the system that led to the crisis of oxygen cylinders, though the government denies this allegation. HOW TO STRENGTHEN PUBLIC SECTOR STRENGTHEN AND ENCOURAGE: Instead of subsidising private companies, the government should look to strengthen existing systems and encourage people to avail the services. The inability and ineffectiveness of the public health care system is indirectly encouraging the privatisation of health care services. FOCUS ON ADDITIONAL REVENUE: The government needs to focus on developing innovative and alternative streams of revenue rather than subsidising and passing the buck to the private sector. A health cess, similar to the education cess, where taxes for certain goods and services would include a health tax component, can be considered. INCREASE THE SPENDING: The National Health Policy recommendation to increase public health allocation to 2.5 per cent of the GDP is a welcome step in the right direction. To be really effective, the increase should have been up to 4-5 per cent. It is imperative that the government realises the centrality of health in the growth of a nation. Countries that have robust public health systems spend much more Canada and the UK spend 8% of their GDP on healthcare. This along with corruption free administration can help public sector. CONCLUSION Privatising district hospitals can have right impact when state governments regulate them through measures like prescribing generic medicines [Jan Aushadhi outlets], procuring medical equipment in transparent manner, option to provide NEO IAS 0484-3190310, 9446331522, 9446334122 Page 8
services at low cost under Corporate Social Responsibility and regional medical insurance schemes, Incorporating Traditional AYUSH systems along with modern methods etc. The intention of NITI Aayog is right but implementation must be regulated so as to ensure justice to all and achieve goals of Sustainable Development Goals-3 in India. Therefore, it is imperative to ensure that the association with the private sector is rooted in principles of justice rather than merely financial expedience. NEO IAS 0484-3190310, 9446331522, 9446334122 Page 9