An unhealthy step

PPPs in urban health are a terrible idea

After dilly-dallying for years, the Union Cabinet has finally given its nod to the Rs 22,500-crore National Urban Health Mission (NUHM) to provide basic health services to nearly 78 million economically disadvantaged people in roughly 780 cities. While a similar mission on rural health management came into being in 2005, the NUHM got stuck due to divergence of views between the Planning Commission and the health ministry on the role of the private sector. The ministry, as also several state governments, correctly had reservations about relying heavily on public-private partnerships (PPPs). But it is the writ of the Planning Commission, mistaken though it is, that seems to have ultimately prevailed. The mission is stipulated to function through a mix of public institutions - including railway hospitals and public sector companies' hospitals besides the existing health infrastructure - and PPPs at all levels, including private practitioners. Their services are to be reimbursed at predetermined rates.

At present, India's public and private health sectors operate on two contrasting planes. While the former, meant largely for the poor, is underfunded, understaffed, overcrowded and inefficiently managed, the latter, which caters chiefly to those who can afford it, is flourishing, rapidly modernising and striving to offer world-class facilities with an eye on capitalising on medical tourism. It seems there aren't too many opportunities for worthwhile collaboration, because private investors seek returns that may not be possible through the government's bond rates. The reluctance of private hospitals to open up their facilities to have-nots is well reflected in these health care providers' abysmally poor compliance with their contractual obligations to treat a certain number of patients free or at concessional rates, to compensate for cheap land and other facilities obtained from the government. In any case, the incentives for defrauding the government that exist in any PPP set-up become doubly dangerous when a patient's health is involved.

The primary health care needs of the urban poor will have to be met primarily by the public sector. At best, the private sector can serve as the second tier under a well-designed referral system. A sufficient expansion of public health infrastructure seems impossible without the help of the states - which have not been fully utilising even the central funds allocated to them. The country's total public spending on health management, at present a paltry 1.2 per cent of the gross domestic product, is less than half of what other developing countries spend on average. It is true that this needs to be increased, but it appears to be a tough goal to achieve at a time when reducing the fiscal deficit is essential.

The NUHM's objectives are unlikely to be met unless all the three key components of health management - prevention, cure and recuperation - are taken care of. The present health system is geared basically to treat patients. Prevention - more critical than cure in poorer urban districts - involves public and individual-level sanitation, access to potable water and clean environment. These are the responsibilities of other departments, which would also need to be upgraded and spruced up. Access to drugs at reasonable rates is another problematic area. For some odd reasons, while health, under the Constitution, is a state subject, drugs are in the Concurrent List. This further enhances the Centre's accountability in running the NUHM.