Letters to the Editor
Pitfalls of Public Private Partnership
“To succeed, public-private partnerships in health care need strong regulators.”

cite as: Jesani A. Pitfalls of Public Private Partnership.The Physician 2012 1(1) 60


Recently, it came to light that over 16,000 hysterectomies, most of them deemed unnecessary, had been conducted on women from below poverty line (BPL) families in private hospitals in Bihar. Not long before that, private hospitals in Chhattisgarh had come under scrutiny for the same reason. The operations were allegedly conducted to fleece insurance funds available under the government’s Rashtriya Swasthya Bima Yojna (RSBY). The epidemic of unnecessary hysterectomies had already hit many sections of urban women. With public money easily available under the RSBY, it has now made inroads into rural and remote areas as well. What’s more, such hysterectomies may only be the tip of the iceberg — there are rampant irregularities in the provision of healthcare by the private sector, using public money. It brings into focus serious flaws in the government policy of providing money to the private sector instead of investing it to strengthen and expand public health services.

To begin with, government regulators do not seem up to the task of unearthing such scams and taking action against the perpetrators. According to the reports on Chhattisgarh, the director of health services, under public pressure, appointed a fact-finding team and suspended doctors involved in 22 known cases, although thousands were reported. In Bihar, the chief minister has ordered an inquiry into the matter. Directorates of health services, used to running government facilities, are ill-equipped to regulate the quality and ethical standards of private hospitals and doctors working there. Schemes like the RSBY were launched without building regulatory capacities. Ever since the government launched the National Rural Health Mission (NRHM) and public-private partnerships for the delivery of healthcare, activists in the task forces and working groups of the NRHM and the Planning Commission have argued that the government first needed to put in place strong regulatory agencies that would oversee registration, medical standards, patient protection and rights. They also urged for community monitoring of private healthcare. Policymakers tackled the process upside down, pumping money into the private healthcare sector without strengthening public services, and without setting up a transparent and accountable governance system.

Yet, the practice of partnering with the private sector to deliver public healthcare services is several decades old. In any country where the private sector has been provided funds or land, tax holidays, subsidies and other largesse to help it dispense healthcare to those who cannot afford it, government funds have been fleeced in the absence of stringent regulations and community monitoring. In our country, most of the states do not have effective laws for the registration of private hospitals; neither do they have periodic medical and financial audits by independent regulators. Doctors’ and hospitals’ associations have grown so strong that any attempt to impose regulations has been countered by threats and strikes. Despite the noise made by the politicians and by bureaucrats of health directorates about taking action against the doctors and hospitals, very little is expected in terms of bringing the culprits to book. While it may seem easy to crack down on those who claimed insurance money without doing the surgeries, it is more difficult to prove fraud where allegations of unnecessary surgery are involved. Unless the regulator has the power to take full medical and financial audits, and has protocols for
the treatment of various ailments covered under the insurance scheme, reports submitted by investigators will turn out to be ambiguous. Instead of making a case for a robust regulatory regime, such reports would only lead to a few cosmetic punishments that would be forgotten soon. The unnecessary hysterectomies also point to the neglect of reproductive health and reproductive rights in our public and private health services. Much has been said about the unethical conduct of doctors who generated a “supplier-induced-demand” — women agreed to get rid of a uterus that was giving them “trouble” after the doctors scared them with talk of the potential development of cancer and other diseases. Supply side regulations to prevent irrational and unnecessary medical care ought to be combined with provisions to cater to the reproductive needs of women in rural areas. For that, primary care in rural areas and urban slums must be equipped to look after the reproductive health for women. This should be combined with changes in social traditions and greater awareness about reproductive health problems. In the present set-up of primary healthcare, reproductive health is neglected. Yet when women travel to private hospitals for care, their bodies are deprived of a vital organ, causing long-term damage to their physical and hormonal systems. ■