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A healthy partnership

Strengthening of public health services must go along with leveraging of private sector resources.

Updated: August 19, 2017 11:43:25 am
Gorakhpur Hospital Tragedy, Niti Aayog, Private-Public Partnership (PPP), non-communicable diseases, National Health Mission (NHM), AIIMS, Medical Council of India, Amitabh Kant, Indian Express Editorials, Indian Express News The recent Gorakhpur tragedy is just another reminder of the tragic consequences ultimately borne by our citizens. 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. (Express photo by Vishal Srivastav)

By Amitabh Kant

I read with great interest the article by Sujatha Rao ( ‘A strange hybrid’, IE, August 11) in which she has pointed to the so-called shortcomings in Niti Aayog’s draft proposal offering space in select district hospitals to private players through a transparent, competitive Private-Public Partnership (PPP) framework for the treatment of non-communicable diseases (NCDs). Engaging with alternative points of view is an essential part of a robust policy-making and when it is articulated by Rao, a former Union Health Secretary, it merits detailed consideration.

While she points out the potential cost and equity implications of partnering with “profit maximising” private providers, it is inconceivable that she is unaware of the failings of our publicly provided health services. The recent Gorakhpur tragedy is just another reminder of the tragic consequences ultimately borne by our citizens. 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, it has been shown by Jishnu Das and his colleagues in their study, the effort put in by qualified doctors in government facilities is far worse than their private counterparts.

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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 areas.

All this while, almost as if by default, the 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. In reality, we have abandoned the patient to negotiate this maze, where her bargaining power vis-à-vis the provider is the lowest. Little wonder then that 37 million people face impoverishment on account of health-related expenditure.

While this happens, the increase in government expenditure to 2-2.5 per cent of GDP for the expansion of public health services fails to fructify, and has hovered in the range of 0.9-1.3 per cent from1990 till date. The Niti Aayog is also for enhanced government expenditure on health. In fact, the Aayog, in its draft Three Year Action Agenda, has urged the government to treble its health budget by 2019-20.

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 cancer as an example: India has 750 radiotherapy units against a requirement of 1,300.

Even amongst the existing units, many 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. In my view, the urgency with which the supply shortage requires to be plugged precludes an either/or approach. It requires the strengthening public sector while also leveraging private resources and capacities.

Supply gaps cannot be addressed in the short term. Long-term measures are being put in place through several initiatives, including restructuring the Medical Council of India. However, the intent of this exercise is to experiment with an innovative PPP model to develop capabilities at the district level.

The aim is to ensure that district hospitals provide basic services for the diagnosis and treatment of NCDs at affordable rates or free of cost for those patients for whom the government chooses to cover such costs through insurance or through budgetary grants. This will help decongest tertiary level health facilities, help in the geographic dispersal of skills required for NCD care and provide quality care to people closer home at a lower cost.

PPP models suffer from a lack of evaluation. However, the lack of evidence must not be read as failures. In fact, several PPP initiatives including in the areas of emergency transport services, mobile medical units, provision of free diagnostics service initiative, have been successful as well popular. Another apprehension is the long-run impact on healthcare costs, since private providers do have incentives to over provide high-cost interventions.

Prima facie, this is a compelling argument. But if we situate this in the current context where a majority of patients already go to private facilities, the direction of the cost implication is not exactly clear. We hope that such experimentation would provide data and evidence that would inform the future policy direction.

Global evidence may not be sufficient to determine whether the private or public sector is more efficient in service delivery for health. In the interim, how many lives do we sacrifice to satisfy ideologically-driven pursuits? The Aayog is determined to push for the transformation of our health sector and this PPP framework is only a small part of a larger strategy. We are trying to work with all stakeholders to focus on health outcomes with rankings to measure incremental annual improvements, fostering a competitive spirit amongst states. A similar index has been developed to measure the performance of district hospitals.

Financial incentives have been linked to both these indices. We are partnering with states to provide technical support in order to bring about transformational change in their health systems over the next three years. The strengthening of public sector services must go hand-in-hand with leveraging the resources of all players in the Indian health system. Constructive suggestions are always welcome, but arguments that seek to shoot down innovative efforts, without providing an alternate strategy are frozen in outdated ideology and are self-defeating.

The writer is CEO of Niti Aayog

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