The right to health and medical care is a fundamental right under Article 21 of the Indian Constitution. The government is entrusted with the responsibility to provide health facilities, and the Constitution clearly directs the state to safeguard public health under Articles 39(e) & (f), 41, and 47. Yet, the experience of Andhra Pradesh during the first five years after the state bifurcation in 2014 reveals how easily this constitutional promise can be undermined.
When the state was divided, Andhra Pradesh suffered a severe setback in the healthcare sector. It lost premier institutions, medical seats, experienced faculty, and critical staff. At the same time, the new government formed in 2014 increasingly outsourced routine services to the private sector. In the five years that followed — until 2019 — not a single new medical college, super-specialty department, or major public health institute was established. Instead, the state created 26 public-private partnership (PPP) programmes covering everything from the transport of pregnant mothers and dead bodies to routine blood tests, CT and MRI scans, newborn care, and dialysis.
This outsourcing affected even the country’s most important flagship programme — vaccination. The introduction of PPP models in urban primary health centres (UPHCs) disrupted public vaccination services. This is a dangerous precedent for a country that has successfully eliminated smallpox, polio, and maternal and neonatal tetanus, because weak public healthcare systems create space for the resurgence of polio and delay the elimination of measles, rubella, tuberculosis, and hepatitis B.
The story is similar in the diagnostics space. Services that are inexpensive and technically simple are now largely controlled by PPP operators. This raises serious concerns about the privacy and confidentiality of patient data, substantial cost increase, and promotion of unethical practices such as kickback payments.
For example, in a government hospital in Kadapa district where the CT & MRI scan services were outsourced, more than 100 scans were performed on a single day and cost the state exchequer nearly Rs 1 lakh as a consideration payable to the operator. Such numbers are almost unheard of even in large teaching hospitals in Hyderabad such as Gandhi, Osmania, or NIMS.
When CT and MRI scans are done within the government system and operated by the government itself, the services are not only cheaper but also help identify local disease patterns, improve treatment, and generate revenue for the government. This was clearly demonstrated in 2023, when the government opened CT and MRI centres in Nellore, Ongole, Kadapa, and Srikakulam medical college hospitals.
This highlights a very pertinent point. It is imperative that the government work towards making essential services accessible and affordable to the people of the state, free from exploitation by private parties, and ensure highest attainable standards of health and well-being for all citizens. This objective can be fully achieved only if the public healthcare system is established and operated by the government.
The deeper problem with PPPs pertains to the long concession periods. Some of the contractual arrangements typically run for more than 30 years. The draft agreement released by the present government for the implementation of the PPP model for medical colleges provides for a concession period of 33 years that is automatically extendable by another 33 years. Therefore, for decades, the dependence would be on outsourcing and not on in-house facilities that are significantly more beneficial for citizens.
The contractual arrangement with respect to dialysis services illustrates the advantages of government operated healthcare facilities over private ones. Despite having nephrology departments and super-specialty teaching facilities, dialysis services in several government hospitals remain under PPP control, and the outcomes of PPP-managed dialysis have been questioned in many forums owing to the private operator compromising on operational parameters, thereby adversely affecting the well-being of patients.
Yet, when the government is determined, it can perform remarkably well. In Uddanam in Srikakulam district, the government established a 64-machine dialysis unit and demonstrated such commendable progress that the facility could begin kidney transplantation within six months of inauguration — proving that public institutions can achieve results far superior to outsourced services.
The same contradiction is seen in Special Newborn Care Units (SNCUs). Across the state, these units are run by PPP operators even in medical colleges where paediatric specialists are readily available. These units require only a simple ICU setup and a paediatrician, resources that Andhra Pradesh does not lack. In striking contrast, the government established the Padmavathi Paediatric Heart Hospital in Tirupati in 2021, which has successfully performed 4,300 complex heart procedures and 20 heart transplants within three years, all under the Arogyasri scheme, with success rates comparable to the best centres in the world.
Achievements of this scale have rarely been reported in any Indian state since independence. This is the kind of excellence that can be achieved if the government is truly committed towards healthcare.
The COVID-19 pandemic further highlighted the strength of government institutions. The highest number of patients were treated in government hospitals, which proved unmatched in their ability to expand services during an emergency — whether it was providing oxygen lines, ventilators, Remdesivir, Tocilizumab, maternity care, or major surgeries. This was possible only because of the vast bed strength, dedicated doctors and paramedics, and the built-in flexibility of government systems.
These examples show one thing clearly: when the government undertakes healthcare, it can deliver world-class services; when it withdraws, outcomes decline. PPPs were originally promoted by NITI Aayog to help states with poor health indicators narrow inequality gaps. The objective was to supplement and complement government services, not substitute them. But in Andhra Pradesh, PPPs have increasingly replaced core public health functions. States such as Tamil Nadu and Kerala, which consistently rank at the top in health indicators, have minimal PPP involvement. Their success lies in maintaining full government control, proving that public health thrives when the state leads.
The danger of over-reliance on PPPs goes beyond cost. Most PPP programmes operate in silos, disconnected from the larger public health system. Data collected is incomplete, making it easy to misinterpret disease patterns and to mismanage resources. Once a state slips into this model, recovery is difficult. Contracts are long, governments become dependent, and essential services remain in private hands for years.
Every district should have a government medical college and hospital, functioning as the district health secretariat — the head of the entire public health system. A medical college is not just a place to train doctors or treat patients; it is the planning and referral hub that links primary, secondary, and tertiary care. Without it, the system is leaderless. Recent crises — from COVID-19 to the Uddanam kidney disease, the Vijayawada diarrhoea outbreak, and the mystery illness of Thurakapalem — prove that public health issues must never slip out of government control.
The referral chain — from a village health centre to a tertiary hospital and back — ensures seamless treatment, accurate health records, and reduced out-of-pocket expenditure. This is why the government of India encourages the establishment of a medical college in every district. But when medical colleges operate under PPP models, profit becomes the primary motive, compromising standards of care and teaching. Education becomes costly, patient care becomes substandard, and responsibility is blurred between the government and the private partner. The only clear winner is the private vendor, while the people lose their constitutional right to health.
In fact, the government that was formed in 2019 worked with this philosophy, formulated and embraced the admirable programme of strengthening healthcare infrastructure in the state and has demonstrated considerable progress. Five of the 17 medical colleges and teaching hospitals have commenced operations, two others received letters of permission for seats. It is also admirable that government medical colleges, including the new medical colleges, had nearly 100% faculty in 2023-24 as against 50% to 60% in most of the private medical colleges and 68% in AIIMS New Delhi.
However, the new government that came to power in 2024 has resolved to adopt the PPP model and is handing over 10 medical colleges to private operators. It is quite distressing to note that these 10 medical colleges are at various stages of construction and with some allocation of financial resources, they can be completed and operated under government control. If this arrangement crystallises, these 10 districts would be permanently deprived of a government medical college and hospital that would have functioned as the apex body for each district’s healthcare facilities.
Andhra Pradesh has infrastructure and human resources comparable to Tamil Nadu and Kerala, which consistently lead national health rankings. The difference lies in commitment. Those states maintain strong, government-led health systems and have avoided large-scale PPPs. Andhra Pradesh, too, can provide affordable, high quality healthcare — but only if it reclaims full control of its public health services and treats health not as a commodity but as a right guaranteed by the Constitution.
Dr B Chandrasekhar Reddy is a senior neurologist and former chairman, Andhra Pradesh Medical Services and Infrastructure Development Corporation.
Views expressed are the author’s own.