During the monsoon months, when vector and water-borne diseases sweep through Barwani, the 400-bed district hospital overflows with patients, with many huddling on the floor.

Throughout the year, beds are scarce in the government-run hospital – the only major health facility that most people in this Adivasi belt in south-west Madhya Pradesh can afford to access.

The scarcity could soon grow worse.

The Madhya Pradesh government has decided to allocate a quarter of the beds in all district hospitals that it runs to private organisations, who will then set up medical colleges. Urban development minister Kailash Vijaywargiya said this has been done to incentivise the private sector to invest in healthcare and improve hospital infrastructure – a recommendation first made by the central government think tank Niti Aayog.

But health activists fear that this would adversely impact healthcare access for the poor. While public hospitals are bound to provide free treatment, the private organisations have been allowed to charge fees on 25% of hospital beds.

At the Barwani district hospital, the new rule means that 100 of the total 400 beds will no longer be available for free treatment. “If the available [free] beds are reduced, where will poor patients go?” asked Amulya Nidhi, health activist with Jan Swasthya Abhiyan. “Already, government hospital beds are falling short.”

Madhya Pradesh has 55 district hospitals and 12 government medical colleges. State government data shows there are 16,850 beds in 52 of the 55 district hospitals. A 25% reservation will lead to the allocation of more than 4,200 beds for paying patients.

On March 5, the Jan Swasthya Abhiyan, a collective of health activists, wrote to the state government pointing out that the plan will deprive the poor of affordable treatment.

The premises of the Barwani district hospital. Credit: Special arrangement.

The Niti Aayog model

In 2017, government think tank Niti Aayog had recommended that district hospitals be operated through public-private partnerships to improve health infrastructure across the country.

The think tank updated the guidelines in 2021 to link district hospitals with private medical colleges. The guidelines state that the government will provide land and basic infrastructure in the form of a district hospital to a private partner, which has to invest in developing a medical college.

The Niti Aayog’s justification is that government hospitals suffer from a dearth of qualified doctors and that the government alone cannot bridge the gap in medical education.

The National Medical Commission requires a minimum number of hospital beds to start a medical college, based on the number of MBBS seats proposed. The provision of government hospital beds will make it easier for a private player to get permission to start a college.

In 2023, the Uttar Pradesh government approved the handover of six new medical colleges under the public-private partnership mode. The same year in Maharashtra, the state government announced it will hand over the Aundh district hospital to private companies to increase its facilities and bed strength. Health activist Abhijeet More said this led to multiple protests. The project is on hold for now.

If Madhya Pradesh implements its new proposal, it might become the first state to hand over beds in all its district hospitals to private organisations and convert them to medical colleges.

A crowded hospital in Rajasthan during a strike, in this file photograph. Credit: PTI.

Past attempts

Madhya Pradesh’s experiments with a similar model in the past have been unsuccessful. In 2015, the state government handed over the Alirajpur district hospital and a primary health centre in Jobat, both Adivasi-populated areas, to a Gujarat-based non-profit.

According to the agreement, the state government would pay the salaries of some doctors while the non-profit would pay for the rest of the staff. SR Azad, a health activist, told Scroll that the government did not issue a tender and directly appointed the non-profit to take over the hospital.

“The government told us that the decision was taken to improve the maternal mortality rate, neonatal mortality and rate of anaemia in the region,” Azad said. But the non-profit had no prior experience of working in Madhya Pradesh.

Azad said that in the one year that the non-profit managed the hospital and healthcare centre, there was no significant improvement in the local region’s mortality rate or anaemia. The National Family Health Survey, 2019-’21 showed that anaemia among children under the age of five increased from 74.5% in 2015-’16 to 76.4% in Alirajpur.

In 2016, the Jan Swasthya Abhiyan filed a public interest litigation in Jabalpur High Court against the public-private partnership model. “It is the government’s responsibility to improve the health indicators in a district,” said Azad, explaining the petition’s rationale. “They cannot put the responsibility on private players.”

The court ordered a stay on the public private partnership in Alirajpur in 2016, Azad said.

In 2021, the state government handed over a community health centre in Sanwer in Indore district to the Aurobindo Institute of Medical Sciences. The community health centre covered more than 150 villages.

The government was forced to stop the pilot project the same year following local concerns that it would increase the referral to Aurobindo hospital where patients will be forced to pay for treatment.

Despite these failed attempts, on March 4, the state cabinet approved a proposal to involve private organisations in creating new medical colleges by handing over government district hospitals to them.

Nidhi, from Jan Swasthya Abhiyan, said the consistent attempts of the government shows “they are either not willing to take responsibility of public hospitals or are creating favourable policies to benefit privatisation”.

Madhya Pradesh additional chief secretary for health Mohammad Suleman and medical education commissioner Tarun Pithode did not respond to calls and messages from Scroll. Principal secretary for health, Vivek Porwal, told Scroll that he has recently joined his post and cannot comment on the cabinet meeting’s decision to hand over district hospitals.

Karnataka’s failed model

Two decades ago, the Karnataka government tried to implement a similar model. In 2002, the state government set up the Rajiv Gandhi Super Specialty hospital in Raichur and handed over the 73-acre campus with hostel, staff quarters and hospital building to Apollo Hospitals Enterprise Limited to provide specialised treatment for various diseases.

The state government drew up an agreement to pay Rs 1 crore per month for revenue expenditure to Apollo. Under the terms of the agreement, the private hospital would have to provide free treatment to below-poverty-line patients in Raichur.

A decade later, a state government inspection of the hospital found that it lacked several services that were part of the agreement. Out of 340 beds, only 154 were functional, of which only 58% were occupied by patients in 2010-’11. The below-poverty-line patients admitted covered only 11% of total beds in hospital.

In May 2012, the Karnataka government terminated the agreement with Apollo.

In 2022, the Karnataka government again decided to hand over nine district hospitals to private organisations to run them as medical colleges. Gopal Dabade, president of Drug Action Forum, Karnataka, said there were massive protests in Chigateri in Davangere district where the local district hospital was part of the handover.

The decision was rolled back when Congress came to power in 2023 in Karnataka. Local activists, however, say that the government is still considering a partnership with private agencies for healthcare.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.