The potential of India’s district hospital system to dramatically expand access to quality secondary and tertiary health care has never really been realised. The majority of patients today use the facilities created mostly by for-profit urban hospitals. That asymmetry could potentially be offset, though only in small part, through the proposal of the NITI Aayog and the Union Health Ministry to allow private entities to use the premises of the district hospitals to provide treatment for cardiac and pulmonary diseases and cancer. Viewed in perspective, a quick scaling-up of care for such non-communicable diseases is possible under the arrangement, because there are 763 functional district hospitals, with just five States led by Uttar Pradesh accounting for over 42% of the facilities. Yet, contracting out services in a virtually unregulated and largely commercial private system is fraught with risks. One major concern in such an arrangement is to ensure that the bulk of health spending, whether from government funds, subsidy or private insurance, goes into actual care provision, and that administrative expenditure is capped under the contract. Moreover, in consonance with the goal to provide health for all under the National Health Policy, care should be universal, and free at the point of delivery. A market-driven approach to providing district hospital beds for only those with the means would defeat the objective.
Providing 50 or 100 beds in a district hospital may expand access to care, but such arrangements do not offer a cure for the larger problem of the growing non-communicable disease burden. Lifestyle choices and social determinants, such as tobacco and alcohol use, and environmental pollution, are often linked to such diseases. Controlling the epidemic, therefore, requires other policy approaches too. Given the already high prevalence of cardiac and pulmonary conditions, some arising from diabetes and hypertension, and cancers, having more beds for treatment is a necessity. It is incongruous, however, to opt for contracts of 30 years, given the move towards achieving universal health coverage and, aspirationally, a single-payer government-led model that mainly relies on public facilities. Strong oversight is also necessary to ensure that ethical and rational treatment protocols are followed in the new facilities, and procurement and distribution of drugs are centralised to keep costs under control. Ultimately, the success of such systems depends on medical outcomes on the one hand, and community satisfaction on the other. Both dimensions must find place in a contract, and be assessed periodically. A provision for audits, penalties and cancellation of contracts is essential. Given the recourse to tax funds for viability gap funding and use of public infrastructure, the operations should be audited by the Comptroller and Auditor General.
