India’s healthcare system seems set to go down the road of increasing partnerships between Government public-health-oriented hospitals and private entities. A direction initiated with the World Health Organisation’s Invest in Health move in the 1990s and pushed by both the World Bank and the IMF, it has today reached a critical point, with the NITI Aayog driving the agenda of public private partnerships (PPP).

Some States have taken the leap and are getting the private sector to manage their Primary Health Centres (PHCs). District hospitals in Tier 2 and Tier 3 cities are also expected to enter into similar partnerships with private entities. What does this mean for the public health system and access to healthcare and medicines? And how does it address the elephant in the room: Conflict of Interest?

Often used in corporate law, “conflict of interest” or “duty of loyalty” is used to describe the involvement of a trustee, person of firm; it requires them to put the organisation’s interests ahead of their own, even when faced with opportunities. Applying this to the State, government officials/representatives are in a position of trust for their duty of loyalty to the citizens of the country—to do public good. They are obliged to work both ethically and legally in the interest of the public, which pays for them.

In a PPP, conflict of interest often sees the private partner being part of the decision-making process. And while a PHC cannot deny treatment to anyone, a private partner can. The PPP guidelines for district hospitals stipulate that the Working Groups constituted by Niti Aayog should involve the participation of private healthcare providers, the Health Ministry, an expert group of healthcare providers, and the Confederation of Indian Industry. Evidently, patients were not considered stakeholders who needed to be represented.

The management of PHCs is handed over to the private sector, citing the public health system’s failure in providing quality care in remote areas. However, this has not worked out in Bihar and Rajasthan as the private sector has tended to take over PHCs in locations other than where they were intended. In the rare cases where the public, in this case the Panchayat, is involved, as in Kodagu district in Karnataka, the Panchayats have rejected handing over of PHCs to the private sector.

In district hospitals, partnership with the private sector is only possible if the hospital has 1,000 patients attending their out-patient departments. Further, the onus of ensuring that PHCs and CHCs (community healthcare centres) refer patients to the private partner is on the government. So far, the process of private partnership has been limited to the departments of oncology, cardiology and respiratory ailments, and within them to specific services.

It is in this context that the deaths of children at Gorakhpur’s BRD hospital needs to be seen. The deaths are primarily due to corruption in the system that led to the crisis of oxygen cylinders, though the government denies this allegation.

Going by past actions of the government, and the lack of space for the voice of the people, the PPP comes across as a first step towards privatisation of the entire subcentre, PHC, CHC and district hospital system. PPPs in health have already seen the costs of institutional births and the number of caesarian sections rise for many households. The impact of privatisation of other specialties on the poor can be imagined.

The writer has been working on conflicts of interest in health and nutrition for ten years. Views expressed are personal.

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