By Rama V Baru
The Covid-19 pandemic has generated a lot of discussions on the role of private sector in India’s healthcare sector. There has been discussion about the need to regulate the private sector. If we want to talk about revamping the public health system, we need to discuss the elephant in the room — the extent and the nature of the private sector and the way it has spread its tentacles into the public health system. We need to identify the commercial ideas that have already creeped into the public system, whether it is on provisioning, drugs, technology, or medical and nursing education.
If you have to conceptualize the revamping of the public health system, we have to engage with the diverse and extensive presence of the private sector in these various subsystems of the health service system. I just want to make the point that the public health system has taken a beating for its performance because of the rampant commercialisation outside. There is a demand to ban private practice by government doctors.
Several states have tried it over time, but that has been resisted. But the other very important aspect of commercialisation is the contractualisation of health workers. So, ASHA workers are not the only ones on the fringes of the system. Many states hire doctors on a contract basis. The question arises is what kind of commitment we could get from that kind of engagement. If you’re working on contract basis, you’re constantly thinking of getting a next better job.
Public health system in the shadow of privatisation
Archna Diwate and I have done a paper for the India higher education report. When we looked at the data for medical education, nursing, or allied professions, we found that this sector is highly privatised. It was quite shocking to see the proportion of private sector to public sector institutions. The proportion maybe 50-50 or 60-40. There are some states where it is really skewed, especially the southern and the western states.
When you have a highly commercialised medical and nursing education, what kind of public ownership of the health system can you inculcate at the level of values and commitment? These are some of the issues that are constantly coming up. And when you look at diagnostics and drugs today, much of it is in the private sector. When we are looking at revamping the public sector, we have to look at it in terms of the power dynamics. You do find that the corporate and the middle private sector is able to influence policy both at the central and state levels. And this has been happening for quite some time.
I just want to raise the issue as the Covid-19 has provided an opportunity to revamp and strengthen public health systems. If you look at the NITI Aayog reports for the last five years, you find that there has been a very systematic roadmap for greater privatisation. When they talk about more medical colleges, they’re talking about increasing the number of private medical colleges which will then partner with district hospitals to provide a greater capacity for medical education. Same is the case with nursing education and other allied professions.
Policy skewed towards privatisation
The roadmap provided by the NITI Aayog is asking for greater foreign direct investment in health. You’re talking about the import of technologies for health, and about the importance of building public-private partnerships. We have discussed why public-private partnerships are not the way forward, but the reality is in the power dynamics that is being played out. More insurance — public insurance for the poor, greater spaces for private insurance.
Corporate hospitals today have diversified — they are no longer the phenomena in metro cities. They have reinvented themselves and have created the hub and spokes models for getting into smaller towns and making their presence felt. The Covid-19 crisis shows us how in the moment of crisis, the private sector went largely unaccountable. And there has been no effort by the government to actually rein in the private sector, even in the case of a national health emergency.
There have been examples from other parts of the world where there were short-term nationalisation like in Spain. The private sector in India has come to a space where it is able to be in sync with the political class. Of course, they need a public health system where the market cannot be responsible or respond to. At the time of the Covid-19 pandemic, hospital groups said we cannot afford to offer every bed to Covid patients because we will lose our profits. If this is the attitude of the private sector in the time of a national crisis, you start wondering what we can actually do. And the whole regulation story is one of power dynamics.
Regulation of private sector
Of course, the Clinical Establishments Act is very important and it was the result of struggle by progressive movements. But having said that, the resistances from the private sector has been very strong. The questions here is that how to regulate the corporate sector, and who will regulate it. The corporate sector is closely allied to the ideology of the present government. The central government apparatus is urging greater privatisation on one side, and also talking about building public systems. We are in a confused system, which is skewed towards the privatisation agenda.
How do you deal with this situation? The other very important aspect is that there has been a nonprofit sector in the country. There have been networks of hospitals that have continued to do very well. But they are also facing the onslaught of commercialisation like the Christian Medical Association and the Catholic Hospital Association. Smaller hospitals, dispensaries, and clinics are serving populations where there is a weak public health system. There is pretty much no private system that is operating in those spaces. Now they are being forced to close down because they don’t have the kind of funds to face competition from the private sector.
There are larger hospitals in the nonprofit sector that have actually transformed and commercialised themselves. Many of them today resemble corporate hospitals. I think the power of the market, the power of the private sector, has actually been distorted. We can continue to fight for strengthening of the public systems. And I think it’s very important to recognise that as we fight for strengthening public systems.
(Rama V. Baru is Professor at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi.)