Maharashtra: Is setting up medical institutes under public-private partnership a good route?

Maharashtra Image Courtesy:mid-day.com

Aimed at expanding the health infrastructure in the state, especially in rural and semi-rural areas, the Maharashtra government has reportedly decided to set up new medical colleges and super-speciality hospitals on a public-private partnership (PPP) basis.

This partnership between private and public players involves financing, designing, and decisions on infrastructure facilities that were initially provided only by the public sector. According to media reports, the government believes that in the next three years, additional 1,000 seats in MD (Doctor of Medicine), MS (Masters of surgery) and DNB (Diplomate of National Board) courses will be created. In the next ten years, this plan envisages 2,600 more MBBS seats, including 1,800 in the new medical colleges and 800 in the present colleges.

Maharashtra Medical Education Minister Amit Deshmukh was quoted by NDTV saying, “Every district will have a medical college. At present, 18 districts have government medical colleges. There are proposals to set up medical colleges in eight districts. We will utilise the Central government’s scheme and funds for (setting up the health infrastructure) in Maharashtra.”

Vulnerable health infrastructure

The pandemic, especially the devastating second wave has exposed the crumbling healthcare infrastructure in India. In February 2021, the 15th Finance Commission report had revealed that the doctor-population ratio in India is 1:1,511 against the established World Health Organisation recommendation of 1:1,000. The nurse to population ratio is 1:670 against the norm of 1:300.

Further, the report also reflected poorly on the hospital beds-to-population ratio. “India is estimated to have a total of 18,99,228 hospital beds (over 60 per cent of which are in the private sector), that is, roughly 1.4 beds per 1,000 population. This is lower than in many comparator countries: China’s bed density exceeds four per 1,000; Sri Lanka, the United Kingdom and the United States have around three per 1,000; and in Thailand and Brazil, hospital beds exceed two per 1,000 persons,” it said.

The report submitted to the government also said that among the major states, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Maharashtra and Uttar Pradesh are way behind others in government doctors to population ratio. The National Health Policy 2017 (NHP 2017) recommended the ramping up of public health expenditure to 2.5 percent of GDP by 2025. It said that States’ spending on the health sector should be increased to at least 8 percent of their respective budgets by 2020.

But as per the latest data (NHP 2018 to 2019), except Meghalaya, all states are spending less than 8 percent of their budget on the health sector. Punjab, Telangana, Maharashtra, Haryana, Madhya Pradesh, Karnataka, Uttar Pradesh, Andhra Pradesh, Bihar and Nagaland are spending less than 5 percent of their budget on health.

PPP, a good model?

It is a known fact that there is a vast disparity between public and private healthcare and the maximum population, i.e., the rural areas depend on public systems/government facilities. The National Health Profile (2019) also shows how health continues to be a low priority for the government, with low public healthcare spending, compared to other nations, at around 1 to 2 percent of the total GDP. On the other hand, the private sector runs on a for-profit basis, and hence offers better equipment and services that pander to the limited urban population.

Karnataka was one of the first states that tried to implement PPP in the health sector and allegedly failed. According to a New Indian Express report some experts were not happy with the results. Dr M Madan Gopal, former principal secretary to health and family welfare department had told the publication, “There have been examples of failures in Karnataka. For instance, the PPP for primary healthcare, the Arogya Bandhu scheme, was 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 the primary health centres.”

The failed model of the Rajiv Gandhi Super Speciality Hospital, in Raichur, Karnataka in tie-up with Apollo Hospital is not news to anybody. For this project, the government had reportedly provided 73 acres land, the hospital building, roads, power, water facilities and a financial aid of Rs. 60 crores. But after the state government evaluation in April 2011, it was found that there was poor governance, and grievance redressal mechanism in the hospital. As per the media, the contract was terminated in May 2012 and the hospital equipment worth Rs. 37 lakhs was seized by the Principal District and Sessions Court for unpaid dues.

Health activists and doctors, have in the past, expressed concern about the quality and access to healthcare for poor patients and also the inevitable privatisation of medical education. Giving power to private players to encourage medical education seems to come across as a rather shaky plan. Medical education in India has also been rocked with a series of scandals.

The Vyapam scam from Madhya Pradesh, that involved the employing of imposters to write papers, manipulate exam hall seating arrangements and supply forged answer sheets by bribing officials, led to the cancellation of licenses of close to 700 doctors. In October 2019, the medical seat scam in Karnataka was exposed, wherein three private medical colleges blocked around 60 percent of the seats allocated under management quota and then sold them to students who secured low ranks. This was allegedly done by the medical college management paying off bright students to crack the NEET medical exam. After these students opted for seats in the respective colleges, they would later give them up, thus allowing the colleges to sell these seats for inflated prices, as they are ‘unoccupied’. As per a report in TOI, a seat worth 5 lakhs was sold for 50 lakhs.

Another issue with setting up medical colleges using the PPP model would be sudden fee hikes. For instance, in 2019, Shri Guru Ram Rai Institute of Medical and Health Sciences in Dehradun had increased its fees to around 13 lakhs from 4 lakhs per annum, for seats under the national quota category. The private medical and dental colleges association in Telangana has also asked for an increase in fees, on grounds of “inflation”. This will remain to be a cause of concern.