Bijoya Roy’s work is at the intersection of food and nutrition, social work and public health, and she works with the Centre for Women’s Development Studies (CWDS). Her research focuses on public-private partnership (PPP) models in healthcare in India to examine commercialisation, childbirth practices and midwifery and healthcare workforce casualisation. Recently, her interests have led her to explore the intersection of neoliberal policies in healthcare, inequalities, gender and violence.
In this conversation with TTE, Bijoya analyses how PPPs have shaped the healthcare sector, redefined the role of the state, and influenced health-seeking behaviour over decades in post-liberalised India.
Your work has largely focused on the PPP models in healthcare and how these models have influenced the roles and responsibilities of the state. What has been the journey of PPPs, so to speak, in healthcare?
My work began by looking at the private and public sector healthcare systems in West Bengal in the early 2000s. It was a time when private healthcare sector was expanding in West Bengal. A lot of doctors working abroad, particularly in America, were returning home and establishing hospitals. Other sectors and businesses were also beginning to invest in private healthcare in a big way. Before 2000, the private health sector in Bengal was like a cottage industry – small nursing homes, clinics and hospitals, with [just] a few big facilities. In fact, in the early 2000s, West Bengal was known to have one of the largest public sector healthcare systems.
Early this millennium, the state-funded tertiary and secondary hospitals saw the emergence of contractual ancillary services and PPP-based diagnostic services. At the same time, the state government’s budget in terms of healthcare expenditure remained low. PPP was seen as one of the routes to expand healthcare services, particularly in terms of institutional care. Gradually, PPPs expanded within the larger national health programmes like maternity and child healthcare services (particularly in malaria), eye care (such as blindness control) and in various tuberculosis programmes as well. They also entered ancillary services (food, cleanliness), hospital infrastructure, and even dprimary healthcare centres in rural areas.
So how do the PPPs affect the healthcare we get?
One has to understand PPPs in the context of large budget cuts in state health expenditure on the one hand, and the expansion of the private sector on the other. After the mid-’90s, we see a large section of service provisioning in government hospitals being outsourced to the private sector.
Now, the policy thrust is geared towards the government buying the services from private sector. So, in a way, the state is privatising its own duties. In fact, the state goes on to subsidise the private sector in certain ways like with the Viability Gap Funding*, so that it becomes commercially viable for them to operate in the public sector.
We have to recognise that the main objective of the private sector is profit maximisation [versus government healthcare’s objective of people’s welfare].
By the mid-2000s, PPP models were seen in the government secondary-level district hospitals and tertiary hospitals/ medical colleges and hospitals. They started with the provisioning of high-end diagnostic services like MRI and CT scan. It is also an area where you have a certain profit margin. Later on, PPP models also entered the general diagnostic services [pathology/blood tests, etc.] and expanded further.
When we look at studies conducted in different states like Chhattisgarh, Punjab, Delhi and West Bengal, we see that apart from ancillary services, diagnostics is one of the main areas where PPP models have been applied. So, PPPs are now substituting direct service provisioning that was earlier the state’s responsibility.
*Viability Gap Funding: The provision of financial support by means of VGF for PPPs in economic and social infrastructure projects.
“Now, under two new schemes, private sector projects in areas like wastewater treatment, solid waste management, health, water supply and education, could get 30% of the total project cost from the Centre,” adding that states could chip in with another 30% and the rest can be private sector investments. (As of Nov. 11, 2020)
Thus, the state provides subsidies to private participation in the social sector and makes it a financially viable project for the private sector.
A commonly held view is that private healthcare brings in stringent quality control, improved services and direct accountability. How do you see this?
PPPs are very complex structures and are being promoted in LMICs (low to middle income countries) like India, [on the ground] that they will increase investment in healthcare infrastructure and bring in efficiency, stimulus, etc etc., all of which are constitutional duties of the state. The monitoring of these partnerships requires much greater thoroughness. Over the years, as the PPPs expanded, local authorities and the state government are now playing the role of a steward, overseeing everything, while the private sector looks after the operational aspects. PPP contracts are long-term and span over years. Now they can stretch for as long as 20-30 years.
Being thorough over the PPP life span of a project is a challenging task. It means authorities will have to oversee and monitor multiple contracts at regular intervals. This requires trained workforce with high levels of expertise [from different fields] to do the job consistently and well. But it is not unusual to see a workforce weaken over time at the administrative level across the different levels of authorities.
Studies from Latin America show that when PPPs are renegotiated in between their running period, costs increase in a big way. The taxpayers’ money accounts for all of this eventually. But do the citizens benefit from all this? That is the question.
Nobody is saying that the private sector cannot exist, but it needs a lot of regulation and monitoring. One of the demands has been that price rates should be put up clearly for all to assess and know the service charges. The patients should know the pricing of the services before availing them. Covid has also repeatedly shown us how accessing private healthcare has strained people financially, incurring debts.
But people also hesitate to access public hospitals. Why do you think that is so?
One thing is that the public-sector healthcare (in terms of PHCs, hospitals, clinical services, diagnostics) has not expanded the way it was supposed to. Our healthcare budget is 1.5 to 1.8% of the GDP, one of the lowest in the world. Private healthcare systems have stepped into not just big cities but also in Tier 2 or Tier 3 cities, even in places where urbanisation is very little. Like in Durgapur or Siliguri, you will find a lot of private hospitals.
In terms of infrastructure and workforce, the public sector has gone down drastically. There have been so many protests by nurses and doctors, lab technicians and public health sanitary workers who have repeatedly brought out the chronic shortage of workforce and precarious working conditions in government hospitals. This has a poor impact on the people seeking care and the overall environment of the healthcare institutions. You may have excellent medical equipment like MRI and dialysis machines or surgery facilities but ultimately you need a good workforce to run all this, be it doctors, nurses or other technicians. So, if an institution does not have adequate and trained workforce and consumables (drugs, injections) it cannot work to its optimum level.
And what about rural healthcare? People may be accessing public sector hospitals much more there than in cities. But again, we see a shortage of workforce and services there. If public sector hospitals and primary health centres provide proper services, along with doctors and medicines, and diagnostics are available and address the health needs, it will create trust and increase footfall.
Also, the middle class is a large section that has moved to private systems thinking that they can afford them. We should also remember that of the top 10 countries, India has the highest out-of-pocket expenditure in healthcare. Covid, especially the first and second waves, has shown how the cost of care has increased drastically in the unregulated private sector and how health coverage is not necessarily adequate. People have had to face a lot of economic distress.
How does increasing privatisation influence gendered access to healthcare?
See, women are seldom the decision makers. What resources will be allocated to whom and negotiation of resources – this is not a woman’s decision within a household. Even if they are earning, women don’t necessarily have control over their incomes.
It has been observed in various countries that when healthcare is privatised, women face difficulties and are among the most affected.
In Africa, removal of user fee charges in facility-based care led to the decline in neonatal death and an increase in facility-based delivery. Similarly, in Nepal, neonatal mortality declined among women from lower castes with similar measures. Women’s ability to make health decision improves when there is no user fee.
Then there is also the question of who gets care. A couple of years back, a study conducted in the children’s cardiac ward at AIIMS revealed that boys are given preference over girls. So, within a family, provision of care is also biased towards male members. In privatised care, resources are more quickly mobilised for the male members of the family.
In employer-based health insurance, women lose coverage, which acts as a barrier to their health and well-being.
In countries like India, a large number of women are in the unorganised sector, so now we are just pushing them further out of the healthcare ambit by privatising and tying everything to insurance.
Do you feel that pre-liberalisation India, which projected a clear socialist approach, had a very different imagination of public health?
The Bhore Committee Report (1946) called for an integrated three-tier healthcare infrastructure providing services to the marginalised, irrespective of their ability to pay. The Sokhey Committee Report (1948) emphasised creating a community health workforce. Subsequently, there was expansion of healthcare infrastructure, drugs and medical technology units. Post-1980s, there has been a major shift.
Post-liberalisation, with privatisation and corporatisation of healthcare, there has been greater enmeshing of financial institutions, technology and markets. Earlier, the understanding of the healthcare system in India was less embedded in complex market networks. The focus of politics has shifted from collective to market values, favouring individualism, choice, competition and privatisation.
In the last 20 years, India has witnessed the re-emergence of communicable diseases like chikungunya, dengue and Nipah in Kerala. It has repeatedly shown that our approach cannot be purely pathogenic or biomedical as we are now faced with the challenges of the pandemic, environment degradation and climate change that also bear relevance to human health. Given our socioeconomic contexts, many factors intersect – poverty, gender, caste, class placement, ethnicity, and spatial location where are we located in terms of our jobs – are we in unorganised or the organised sector and so on.
Social determinants of health have widened the concept of health and its causality, and include factors leading to exclusion and discrimination. But, in approach, our healthcare continues to take a medicalised and disease-driven approach. Alongside, there is a squeeze in government investment in public health and overall healthcare expenditure
What other kind of acceleration is being seen in PPP models?
Apart from hospital infrastructure and diagnostics sector, it is now being proposed to start medical colleges in the district hospitals through the PPP mode to meet the workforce and infrastructure gap. This is besides the proposed model of strategic purchasing of clinical services from private hospitals. This would include not just diagnostics but also other services like surgical procedures.
Also, since the middle of 2000, health insurance funded by the central or state governments has come up in a big way, and that further deepens the process of PPPs.
There are around 48 state-funded health insurance schemes and the central government-funded PM-JAY (Pradhan Mantri Jan Arogya Yojana). These schemes empanel private hospitals through third-party agencies and buy the services from them. A large number of empaneled private hospitals are located in the big cities and better-off districts, thus distorting the access and availability of services.
PPPs got an even bigger push in early 2020 when the pandemic started. It was justified as a greater need for infrastructure at the district level.
In this climate, what do you think are the most pressing debates?
One of the major policy debates is how do we regulate the private sector while simultaneously keeping an eye on the public healthcare system? Second, with the pandemic, we have realised that it is not only the hospitals that come to our help. We need a very strong primary healthcare system.
How do we reimagine these systems?
There is much debate about how the private sector could take over hospital-based services, and primary healthcare systems will look after community-based needs. But the question is how can we keep these two – so disjointed and distant – because all these levels of care are, in a way, inter-connected. This divide further fragments our healthcare structures.
Another important debate: we are realising now, especially with more data and as our understanding of climate change increases, how human health is affected by animal health and the condition of our environment. So, the question is, can this medicalised approach be contained? And is it sustainable?
One of the main domains to look at is our local, community-based health traditions. We find this emerging when we look at maternity care last year, and perhaps we will see it this year also given the pandemic situation. Labour and the birthing of the child in hospitals has become a critical issue in the Covid-19 scenario as women are not feeling safe within hospitals and at the same time face harassment from the [health] providers. So, although midwifery practice is again re-emerging, the community midwives, who are called dais [Indigenous Midwives] in our contexts, need more recognition. So, how do we engage with all this? Because if we don’t, then how do we handle maternal healthcare issues – and many other women’s health issues that the dais have addressed over the ages – in a sustainable manner in low-resource areas and where women can also feel safe and empowered.
Could you elaborate on the role of the midwives?
We did a study on indigenous dais in four states and realised that in contexts where the community, dai practice has been in place for generations. Birthing women felt at ease with the dais and at times asked them to accompany when the families took them for institutional birthing. Constant support of dais at home helped women with home births and also provided support to the new mother and the newborn. Women have learnt from each other over generations through a shared and experiential knowledge system typified by the dai. But when policies do not support this practice, there is a huge knowledge loss at the community level. We have seen how maternal healthcare systems and birthing needs have been impacted due to Covid and the lack of dais put many birthing women in danger while being pushed out from multiple institutions during birth.
The many government schemes for the marginalised, say, for BPL families, or pregnant women… how do they pan out on the ground through the PPP approach?
If we talk about the national insurance schemes like PM-JAY or Rashtrya Swasthya Bima Yojana, there are certain services within these that the public hospitals provide and some that the private sector takes care of. And often, the private sector wants to cater to those services that have a profit margin or revenue generation of some kind.
When the Rashtrya Swasthya Bima Yojana came about, we saw many cases of unwanted hysterectomy on the rise in Telangana and Bihar. The private sector was focused on these services and their pricing. Vaginal hysterectomy was one the largest packages within the set of gynaecological procedures laid out in the insurance package.
In the mid-2000s, there were a large number of state level policies that came up to encourage BPL families to go in for institutional deliveries. The Chiranjeevi Scheme in Gujarat was one such. After birthing in the hospital, the women would be reimbursed the expenses. We saw a sudden rise in the number of caesarean deliveries then.
Similar schemes were started in other states, like Madhya Pradesh. Without proper regulations and monitoring, these private healthcare services actually went against the needs of women because their thrust was profit-making.
In terms of partnerships, most private players are located in urban areas or in better-off districts, so how equitable and accessible they are is also a question. Location of the private providers stops them from reaching the poorest and the most marginalised (SC, STs and OBCs and religious minorities).
Given the current system, what do you think are the ways to achieve accessible and equitable healthcare for everyone?
One of our major demands from the government is to increase the budget allocation for the public sector healthcare system. Without that, the services cannot be made affordable for the common people, especially when large number of our population is in the unorganised sector.
Two, the issue of the healthcare workforce is critical. We have a huge shortage of nurses, doctors, paramedical and non-medical (ward helpers, sanitary workers) workforce in our healthcare system. Vacancies over the years have created huge gaps. A large proportion of the positions, clinical and non-clinical, have been casualised. They are now more than the permanent posts. This has led to precarious jobs over the years with poor wages. Group D staff are the first among the few posts in the government hospitals to be completely contractualised. This has deepened the shortfalls in public sector healthcare institutions.
Three, we need strong regulations of various kinds. There are a number of PPPs operational, right from community health to state or central government-run hospital level, which makes monitoring difficult. If you are inviting PPPs, they are one of the most complex contractual agreements, as I said earlier. And as the information on PPP terms and conditions are not openly available for public scrutiny in the name of business secrecy, it makes regulation and monitoring very important and difficult at the same time.
