Can ppp model deliver?

Medical Education
By Dr. Oishee Mukherjee

It is an unfortunate and well-known fact that the country suffers from an acute shortage of doctors and nurses. Specialists are rarely found in sub-divisions, few are located in small towns and most are concentrated in big cities. Obviously, this sends out a terse message to our policy planners the urgent need to expand health infrastructure and in fact medical education so that it can partially meet the requirements. The Centre as well as State governments have over the years decided that district hospitals should henceforth be set up with public-private participation, meaning in real terms that the private sector take over these health centres.
It is therefore pertinent and prudent to analyse what does it cost to become a doctor and the charges that those wanting to do MBBS entail. As per available data, about 28 per cent of such seats cost over Rs 10 lakh officially but around Rs 50 lakh unofficially. The high fees, obviously, makes these seats a quota for the rich, even larger than those for the SC (15 per cent), ST (7.5 per cent) or OBC (27 per cent).
In fact, about half the seats in private colleges are in the management quota or NRI quota. For all these seats, the total official amount, approved by the Medical Council of India (MCI) or the Dental Council of India (DCI) almost triples for candidates who are enrolled. Even entrance examinations, which are held in medical and dental colleges, are manipulated and those giving the extra amounts find their names in the final list. States like Karnataka, Rajasthan and West Bengal charge heavy premiums, sometimes going up to Rs 80 lakhs.
Even some government colleges, mostly in Rajasthan and Gujarat have management seats. These quota seats range above Rs 10 lakhs, going up to Rs 20 lakhs per annum. In fact, some other States are also planning to introduce management quota to meet their expenses as the official support is meager. Apart from these costs, one must also consider hostel charges and other attendant expenses.
If one considers that 80 per cent of Indian families earned around Rs 10,000 per month, the educational charges for private medical and dental colleges are affordable for the rich and the upper middle class and others would have to take recourse to bank loans. At the same time, having spent a high amount for education in private medical colleges, the doctors would concentrate on recovering the amount by opting for big hospitals in cities and not have the commitment to serve the poor and impoverished.
The other problem of medical education is the need for its spread and this can only happen if many more such hospitals with medical colleges are set up in districts and sub-divisions. However, the PPP model wouldn’t work well as again the private sector would be looking at making profit. So the question is will private medical colleges look into the larger interest of serving the society and offer options for lower income groups.
Besides, a close look at the recent budget is necessary, where health has been allocated Rs 2.23 lakh crore for ‘health and well-being.’ But this amount includes outlays for drinking water and sanitation (Rs 60,030 crore), nutrition (Rs 2700 crore), Covid-19 vaccine related allocation (Rs 35,000 crore) and Finance Commission’s grants (Rs 48,214 crore for health and water and sanitation). The allocations reveal that the budget for health and family welfare has decreased in absolute terms by Rs 8349 crore from 2020-21 (from Rs 85,251 crore and revised estimates Rs 76,902 in 29021-22). The government’s flagship programme, Ayushman Bharat has not seen much increase while the National Health Mission (NHM) in rural and urban areas has been increased by a paltry amount.
The only silver lining is that the PM Atmanirbhar Swasth Bharat Yojana shall have an outlay of over Rs 64,000 crore over a period of six years to upgrade primary, secondary and tertiary care facilities, strengthen existing heal institutions, building new institutions for research etc. However, all these are at the announcement stage with no reflected in the budget document.
In such a situation, the government has virtually no plans or programmes to set up hospitals to impart medical education on a bigger scale. The need for medical education being within the reach of the lower segments of society is what it needs to ponder over. This also brings to the fore the bigger challenge of various health facilities being made available to the marginalised sections.
The elitist character of successive governments, and including the NDA, sadly has not given the health sector the attention it deserves so that prevalent communicable and non-communicable diseases are brought under control. Moreover, if students from low income groups of rural and semi-urban areas get medical education, the shortage of doctors in the countryside will no longer be a problem and adequate health facilities could in the near future in rural health centres may become a reality.
It is indeed tragic that while we boast of being an emerging economy, the allocation towards health has been much less than most countries in spite of repeated promises. Even in the recent Economic Survey it has been pointed out that India should increase its spending on health from an average of 1 per cent to 2.5 per cent of GDP, as aspired in the National Health Policy of 2017. Earlier also, during the last decade or so, experts have repeatedly pointed out that at least 2 per cent of GDP should be allotted towards health but this has never been dome.
There is also no sustained action plan about the geographical spread of diseases and the need to set up health centres in rural areas and hospitals in blocks of backward regions. Though figures are dished out regarding shortage of doctors and nurses, precious little has been done, except privatising medical education and facilities that help the upper middle class. For a country of India’s stature, the scenario speaks very poorly of the political leadership and its reluctance to go all out to a lot more as desired.
The government must ask itself whether it really wants that the lower echelons of society to enter the field of medical education as also ensuring that these are not deprived of their rightful due. The elitist and pro-capitalist outlook needs to change so that the silent majority can enter the mainstream of life and activity and ensure a healthy and robust society, at every level. — INFA