India’s apex government think tank has proposed guidelines for private entities to operate existing district hospitals and build, finance and run associated medical colleges under a model that some health experts caution will prioritise profits over healthcare for the poor.

Niti Aayog has released for stakeholders’ comments “guiding principles” for the public-private partnership model to allow private entities to upgrade, operate and maintain district hospitals and establish associated medical colleges with an annual intake of a minimum of 150 MBBS seats.

The guidelines specify that such district hospitals should have at least 750 beds, of which at least 300 beds plus 20 per cent of the remaining beds would be “regulated beds” where patients receive free treatment. A 900-bed hospital, for instance, would have 420 beds for such “free patients, while the remaining 480 beds would be “market beds.”

Patients would need an “authorisation certificate” to avail of the free services, while the private entity managing the district hospital would be entitled to demand and charge “appropriate hospital charges based on market competitive rates from other patients.

A Niti Aayog note announcing a stakeholders’ meeting on January 21 to discuss the proposal said India’s shortage of qualified doctors and the inability of the central and state governments to bridge gaps in medical education with their limited finances necessitate the public- private partnership model.

India has 734 district hospitals that serve as major hubs of free or subsidised healthcare to vast sections of the population. Niti Aayog said the public-private partnership model it has proposed is already operative in some districts of Gujarat and Karnataka.

But sections of health experts are worried that such a model could transform district hospitals from public service-oriented healthcare centres into profit-oriented healthcare centres.

“The district hospitals are the final port of call for the poor across India,” said Abhay Shukla, national co-convenor of the Jan Swasthya Abhiyan, or People’s Health Campaign, a network of non-government health organisations.

“Many of us are concerned that private entities that take over district hospitals might prioritise healthcare for the patients charged fees and de-prioritise healthcare for the free patients,” Shukla said. “We have weak accountability systems that might facilitate such practices.”

Members of a nationwide alliance of doctors campaigning for ethical healthcare said they would examine the Niti Aayog document detailing the guidelines and submit their responses to the think tank.

“This is a disturbing proposal,” said Arun Gadre, a gynaecologist and founder-member of the Alliance of Doctors for Ethical Healthcare.

“The one thing every patient can look forward to now in a district hospital is to be treated equally like any other patient — this will create a hierarchy of free patients and paying patients.”

Shukla said the model will also add more private medical colleges in the country amid concerns about burgeoning numbers of private medical colleges that charge exorbitant fees from medical students. Over half of India’s 539 medical colleges are private colleges.

“Such a model for private operations of district hospitals is likely to drive up healthcare costs,” said George Thomas, an orthopaedic surgeon in Chennai, ADEH member, and former editor of the Indian Journal of Medical Ethics.

“Earlier experience shows that governments are unable to enforce agreements under which private hospitals are supposed to provide free services to patients,” he said.