On June 26, the Chhattisgarh unit of Congress party tweeted a brochure imprint with the photograph of chief minister Bhupesh Baghel. The brochure announced that the government will give grants for the establishment of private hospitals in villages and that Baghel had given the industries department 10 days to prepare a plan.

The next day, the state’s health minister TS Singh Deo publicly opposed the proposal. Deo told Scroll.in the initiative went against the promise of universal healthcare that the Congress party had made in its election manifesto for the 2018 Assembly elections, which it had swept.

“Thousands of crores are being invested in district hospitals, and at the same time if the government gives money to private sector players who charge the public then it is objectionable,” he said, adding that the matter was presumably a proposal since it had not been sent to the health department for approval.

“If we are short of funds we should strengthen public infrastructure. If we are giving money to private players, then ensure that treatment is free of cost,” he said.

It is unclear why the state’s health minister was not involved in the decision. The chief minister’s media advisor declined to comment on the matter. Instead, he pointed to the state’s agriculture minister and government spokesperson, Ravindra Choubey. But when contacted, Choubey refused to comment as well.

Apart from the state health minister, public health experts and activists are critical of the initiative, especially after the coronavirus pandemic has further demonstrated the importance of the public health sector. Across most states, public facilities have treated more Covid-19 patients than private ones, and at a nominal cost compared to the exorbitant charges of the private sector.

“It is highly demotivating for the government to do something like this especially during the pandemic,” said Sulakshana Nandi, the national joint convenor of Jan Swasthya Abhiyan. “This present move is not an honest effort to improve the situation, but rather an attempt to divert public resources to benefit the private sector.”

Involving private players

Public health experts said it is difficult to discern what prompted the Chhattisgarh government to come up with the initiative now. But they pointed to guidelines released in 2019 by the Union health ministry soon after Prime Minister Narendra Modi launched the Pradhan Mantri Jan Aarogya Yojana or the national health insurance scheme.

The guidelines outline methods that state governments can adopt to incentivise the private sector to set up hospitals in “underserved areas”. This includes public investments amounting to 40% of the project cost and allotment of land by the government.

Public health experts had criticised the guidelines, arguing that the Central government was promoting expenditure on private facilities without detailing how beneficiaries could avail affordable healthcare. Instead, they argued the government should focus on strengthening its already existing infrastructure.

Some examples of the benefits of an improved public health system have emerged from Chhattisgarh itself. One of the main problems that state’s health system faced was high attrition of health workers and doctors in districts, said Nandi.

To fix this problem, the state in 2016, introduced a number of interventions in districts like Bijapur, Sukma and Dantewada. These included giving financial incentives to doctors, increasing the amount that bonds medical graduates to serve in rural areas, provision of residential and transport services, upgradation of equipment and better support staff at health centres, according to a study by the state and the World Health Organisation.

Currently, at least 2,011 of the 2,122 for medical graduates in the state have been filled, said Deo, the health minister. “This decision [to increase the bond amount] was taken even before 2018 and we have stayed with it by enforcing it,” he said. “We need to put public money in public infrastructure, salaries, drugs and diagnostics. And to run them we need to ensure we have human resources, otherwise all the money is going to go waste.”

Failed experiments

The initiative to give grants to private players is not the first time that the government in Chhattisgarh has tried to privatise its public health facilities. The state has experimented with public-private partnerships earlier as well.

In 2012, the previous state government under the Bharatiya Janata Party set up mobile medical units, which were designed to cater to the public with a range of health services including immunisation and family planning in inaccessible areas.

But more than a year after the mobile units were launched, the government terminated the contract. The failure of the initiative was attributed to the irregularity of the units’ visits to rural areas and high attrition rates of doctors in these areas, according to a study by Public Health Resource Network and Jan Swasthya Abhiyan.

More such public-private partnerships in the state proved to be futile. In 2017, the state government ended its contract with a private facility in Raipur and decided to run it on its own. In 2018, it gave land to set up Vedanta Cancer Hospital at concessional rates on the condition of treating the poor in Naya Raipur, but the facility did not adhere to the contract.

“The private formal system only cannibalises on an ineffective public system but it does not go where the public system does not exist,” said Dr Yogesh Jain, who runs a community hospital in rural Bilaspur, Chhattisgarh. The government was “hoping that private hospital doctors will go to villages where there are no public systems, but it never happens,” he said.

In 2018, the government had also invited bids for private players to run some of the government hospitals and diagnostic laboratories under a public-private partnership model. Some were also invited to run CT scan, pathology and X-ray services within public hospitals.

The government cited a lack of trained personnel to serve vulnerable groups in remote areas among other factors as the rationale behind these bids. It did not specify if the treatment would be free of cost.

Neither of the projects took off because of a change in the government and a sustained campaign by public health activists in the state, who said that such initiatives did not plug the leaks in the system.

“Why has the government not learnt from the past failures?” said Nandi. “These initiatives are done stating the rationale that it is to serve vulnerable groups in far flung areas but when they outsource it then private agencies do not want to go to rural areas,” she said, adding that only government-run centres were equitable.