Two of the four states that submitted responses to the government think-tank Niti Aayog on its blueprint for a public-private partnership model to tackle non-communicable diseases in district hospitals alleged that the model was created keeping the healthcare industry’s profitability in mind, rather than public interest.

Four states – Tamil Nadu, Haryana, Punjab, and Odisha – submitted their responses to Amitabh Kant, the Niti Aayog’s Chief Executive Officer, between June and July. Tamil Nadu and Odisha sharply critiqued the model. They said the model Niti Aayog had prepared does not hold the private party accountable in any way, as the outcome indicators of the project are not clearly defined.

The draft concession agreement and the guidelines allowing private hospitals to bid for 30-year leases over parts of district hospital buildings, and the provision of land to them to set up 50- to 100-bed hospitals in towns, to treat non-communicable diseases were prepared in May.

The private players who win the bid will provide secondary and tertiary medical treatment for cancer, heart disease and pulmonary diseases at prices that are not higher than those prescribed in state or central government health insurance schemes.

The blueprint in the form of model contracts and guidelines were sent to the state governments on June 5. With health being a state subject, the blueprint requires a buy-in from the states.

Ailments that bring profits and those that don’t

In his response on behalf of Haryana, Dr Satish Kumar Aggarwal, the state’s Director General of Health Services, pointed out that brain stroke had been left out from the diseases to be treated under the public-private partnership model.

Aggarwal said in his written response: “Mostly stroke patients are referred to Tertiary Care facilities resulting in delay in treatment initiation and subsequently poor outcome although stroke patients can be managed at secondary/district level if facility is available. Therefore, stroke component may be included in the MCA [model concession agreement].”

JK Mishra, joint director, Public-Private Partnership and Project Monitoring, Odisha government, raised the same issue and said this was a critical gap in services provided under the model concession agreement. Odisha’s response was submitted on July 26.

Mishra wrote, “There is no mention of emergency and critical care services related to myocardial infarction [heart attack] and stroke. This has been heavily influenced by private sector which has cherry-picked to a large extent, only those services that are profitable, not necessarily services that are critically required to prevent death and disabilities.”

The treatment for a brain stroke, by and large, involves medical management. Very few cases involve surgery or the insertion of a stent. Overall, the treatment is not as expensive as doing an angioplasty on blocked arteries leading to the heart.

Mishra mentioned that the scope of medical services under the umbrella of non-communicable diseases itself is very low, concentrating mainly on “high revenue medical services”.

“The concept in its present form will at most fulfill demand for two to five years and will be insufficient in [the] mid to long term which will necessitate a relook and create complications,” said Mishra. “It is strongly suggested that a medium to long term outlook be taken of the service mix else people will bypass this and go to full service centres anyway.”

(Photo credit: Manjunath Kiran/AFP).
(Photo credit: Manjunath Kiran/AFP).

No accountability and no evidence

In a letter to Kant dated June 22, Tamil Nadu’s Chief Secretary Girija Vaidyanathan said that the public-private partnership model is largely defined from the perspective of inputs – diagnostic procedures, manpower required and on how private providers will be paid for it. “The key performance indicators are also defined without any reference to output or outcome indicators, which is a flawed perspective,” said Vaidyanathan. “The value for money perspective is also missing.”

In his critique, Mishra also pointed out that most of the key performance indicators are related to inputs, and not outcomes. “These will be of limited-to-no use in ensuring quality of care to the patients,” he added.

The model concession agreement does not envisage any third party pre-authorisation of the health interventions, which is done in insurance procedures.

Both Tamil Nadu and Odisha pointed out that there is very little evidence to show that this kind of model works in improving health care.

Mishra wrote that there is no evidence to show that a brownfield project (which uses pre-existing infrastructure) like the one envisaged by the model concession agreement “will be highly dependent on actual ground conditions”. To implement it without proof is impractical, he said. He said that the project needed to be tested in all the states as the ground situation in each state varies substantially.

Vaidyanathan wrote that incentives should be provided to reduce the cost burden to the exchequer. She also wrote that a recent World Bank funded scheme where diagnostic and laboratory facilities were outsourced in Tamil Nadu between 2011-’13 did not succeed in ensuring access to superior health care. Instead, costs went up manifold – the number of procedures increased, and monitoring became difficult, said the Tamil Nadu officer.

Practical difficulties, do not force us

There are some basic practical difficulties too, the state officials pointed out. For instance, Haryana and Odisha government officials said that the precondition of leasing 30,000 sq ft to 60,000 sq ft of land to the private bodies for the 50- to 100- bed hospitals planned is not possible because states and district hospitals do not have that much spare land to give away.

In Odisha’s context, many of the services that are meant to be shared with the private provider, including a blood bank and physiotherapy services, among others, may not be available in these hospitals, said Mishra. He added that sharing of resources of the district hospital is impractical, “creates operational risk” and could result in disputes. He wrote that since district hospitals lack space, the high volume of patients in district hospitals will be crowded out by patients visiting the private set-up handling non-communicable diseases.

Aggarwal from the Haryana government too pointed out that some services that are enlisted in the model concession agreement such as CT scan, Magnetic Resonance Imaging or MRI, and dialysis are provided for a certain category of patients in his state.

The model also misses a linkage to the primary health care set-up, said Vaidyanathan. For instance, a person with coronary heart disease does not necessarily need an angioplasty, and should be followed up with regularly at the primary level. Similarly, patients with high blood pressure also need to be monitored to check if they comply with the treatment. This kind of monitoring can be best done near the patient’s home by field workers. This aspect of controlling non-communicable diseases has not been visualised by the proposed public-private partnership model, she said.

Said Vaidyanathan: “Such a design that only focuses on treatment at district hospital, would not only fragment the delivery of care, but would also potentially weaken the primary health care system which we feel is essential to the success of non-communicable diseases prevention and treatment model.”

She further wrote that the capacity and investment in primary and secondary health care, and the availability of doctors within in the state’s public health system, varies from state to state.

“The choice of whether or not to introduce a PPP [public-private partnership] based approach in this area should be left with the state, and the government of India should not force the state to adopt a particular model,” she said.