A study by an NGO a year after certain rural primary healthcare centres were signed over to private players raises many questions about the way things are being run and the government’s priorities.
Jaipur: A primary health centre (PHC) right in the middle of Rajasthan’s capital was handed over to a noted private hospital chain recently. This move was in line with the Rajasthan government’s stand to improve public health service through private operator participation. Forty-two rural PHCs were handed over to private players at different points in 2016, and 43 urban PHCs were handed over on October 26, 2017. According to activists, the expansion to urban areas took place after private players did not show interest in taking over PHCs in remote locations.
The government has offered to pay upto Rs 30 lakh every year per PHC in return for the private entity taking over the management and all operations. The partnership is initially for a period of three years and extendable for a period of two years. The private operators are now responsible for daily OPD services, distribution of free medicines, free diagnostic tests, vaccination of children and counselling for family welfare services in these PHCs.
However, the PHC that is meant to be in Jaipur’s Gurjar ki Thadi area and has been handed over to Soni Hospital exists only on paper and not physically. Government officials say that the building has been sanctioned but is yet to be built. They are apparently on the lookout to rent another building for the PHC.
This non-existent PHC negates the very basis of the state government’s overriding objective, which is to improve the availability and quality of primary healthcare services and to utilise the technical, financial and managerial resources available in the private sector to fill the gaps in the existing public healthcare system. Rather, the non-existent PHC brings forth the loopholes of the system, which is perhaps designed to benefit a select few.
Another PHC in the urban area of Karauli (around 193 km from Jaipur) is also nowhere to be found. While it seems to exist only on paper, it has nonetheless been handed over to a private player, Chitransh Education and Welfare Society. Health activists finally found the PHC housed in a state government official’s rented home.
These are a few of the key findings of an ongoing assessment by the Jan Swasthya Abhiyan (JSA), an NGO working in the health and equitable development sector. The assessment is being done to study the improvement in healthcare services a year after the state government handed over a 42 rural PHCs to private operators; the organisation has visited 25 of these centres so far.
The government had initially made it very clear that only those PHCs will be brought under a public-private partnership which are in the remotest of areas and where doctors are hard to retain. Chhaya Pachauli, senior programme co-ordinator of the NGO Prayas, who also working for the JSA, told The Wire: “The rampant handing over of PHCs to private agencies is a dangerous thing and its repercussions are going to be grave in the long run. The Rajasthan government, in the initial phase of the PPP, invited bids from private agencies to run only rural PHCs based on the fact that it’s difficult to retain doctors in remote and interior areas. However, when they did not find many takers for the rural PHCs, they later invited private agencies to operate urban PHCs, which was certainly a more lucrative deal for private players, especially for private hospitals which are looking for ways to attract more patients. That’s the reason why within no time, 43 out of 50 urban PHCs which were opened up for bids were taken over by private agencies. I still don’t understand the rationale behind privatising urban PHCs which, unlike rural PHCs, are not located remote areas.”
She further said, “Our observations and findings from our visit to about 25 of the health facilities being run on the PPP mode in different districts have been mixed. While some health facilities were found to be in a better state when compared to others, some were much below the standard. None of the health facilities was found to be doing outstandingly well in comparison to those being directly operated by the government. A few health facilities claimed that there was a rise in OPD numbers after the change, but in terms of infrastructure and basic amenities such as building condition, functional toilets, cleanliness, drug storage, availability of medicines etc, most of them were found to be grossly deficient. In a few villages, community members came forward to share with us their discontent about the way health facilities were functioning after being brought under the PPP mode. A major issue that we came across was that of transparency. Health facilities refused to provide any information to us without permission from the ‘top officials’. This was despite the fact that local community members were a part of the visiting team.”
The assessment team’s study notes that the PHC in Dalot in Pratapgarh district – a model PHC which the government is operating on its own – is running successfully. Four doctors are posted there. PHCs in Achnera and Ambirama, which happen to be just eight km and 16 km away from Dalot respectively, have been handed over to private agencies.
Similarly, PHCs in Richha and in Nithauwa in Dungarpur district, which are only about 10-15 km away from the model PHC in Parsola (with four doctors), have also been brought under the PPP mode.
“If the government can operate Ambirama and Parsola on their own with such efficiency, why can’t they operate other PHCs in the same area without private support?” Pachauli asked.
According to National Health Mission state director Naveen Jain, under the memorandum of understanding (MoU) signed with the private parties involved, the government’s primary aim is to strengthen maternal and child health services in slum areas.
While health rights activists say the main reason in handing over PHCs in rural areas was their inaccessibility, a staff crunch and poor health indicators, they do not understand the need to sign over urban PHCs. Pachauli said, “A few big chain of hospitals which are taking over the PHCs in urban areas are going to treat them as catchment areas from where they can poach more patients and send them to their own hospitals for further tests.”
Choosing private agencies
“We have failed to understand what has been the criterion for selection of these private operators. Why in the world would Apollo Hospital in Hyderabad be interested in running a PHC in Jaipur? And why doesn’t the Chitransh Education and Welfare Society, which has been given at least five PHCs in Jodhpur and Karauli, have a website?” she asked.
Health activist Dr Narendra Gupta, convenor of the JSA, says that initially, 30 PHCs was given to the Wadhwani Initiative for Sustainable Healthcare (WISH) Foundation without them participating in the tender process, as they were willing to put in their own money. Calls to the WISH office in Jaipur, however, went unanswered.
Pachauli said, “There was a sort of silent MoU with Wish Foundation, under the name Lords Education and Health Society, as they wanted to try out some technological innovations in healthcare like diagnostic devices, health ATMs and portable models. If these innovations were tested as successful, there was some sort of mutual agreement that the government would replicate them throughout the state. But later, they returned 11 PHCs to the state government, citing financial problems and local protests. The WISH Foundation now runs 19 PHCs and the government is aiding them financially as well.”
The initial tender was for 299 PHCs but it was revised after activists argued that 299 was a huge number for a pilot project and that many of the PHCs were not in remote areas. There was also objection to the clause that said that the private agency could deliver additional services apart from what a PHC is mandated to provide and charge patients for the same.
After protests, the initial tender was withdrawn in December 2015. A revised tender was issued on December 28, 2015, for 213 PHCs, under the ‘Run a PHC’ scheme, removing the ‘chargeable additional service’ clause. But the JSA’s analysis of the list of 213 PHCs shows a large number of them, across 17 districts, are not located in desert or tribal areas. Locations for some of the PHCs chosen seem to cater more to the private companies than the local populations, activists have alleged.
The PHCs Amba Mata and Siddhpura in Pratapgarh district are barely five km from each other and both on National Highway 126. In Udaipur, five PHCs – Malwa ka Choura (Kotda), Loonada (Bhinder), Savina (Girwa), Kun (Lasadiya) and Sagatra (Sarada) – have been handed over to Geetanjali Medical College and Hospital, Udaipur. Health right activists say these PHCs have been selected so that they can serve as feeder centres for the private medical hospital. This has also been stated in a public interest litigation (PIL) filed by the JSA.
The PIL against the state government, admitted by the high court on May 8, says that free and proficient public healthcare by the state is a fundamental right under the expanded definition of the right to life as set out by several decisions of the Supreme Court. Hence, the state government’s handing over of 213 PHCs under a PPP model is against the spirit of the National Health Policy, 2002. The PIL also says, “It is a invidious privatisation scheme that is ultimately designed to destroy the public healthcare system in Rajasthan and is absolutely arbitrary, illegal and not at all in the public interest.”
Several attempts to reach B.R. Meena, joint director (hospital administration), via phone calls and text messages went unanswered.
The government’s contention in the privatisation move is that inadequate primary healthcare is reflected in the escalating demand for secondary and tertiary services, resulting in overcrowding of hospitals, which lead to high costs and poor healthcare delivery. The government says there is enough evidence to prove that primary healthcare mitigates both costs and suffering.
Aiming for profits
The JSA PIL says that a tender notice for the scheme dated December 28, 2015 was issued without any consultation with the central Ministry of Health and Family Welfare.
When the central ministry came to know about the scheme, C.K. Mishra, additional secretary and mission director of the National Health Mission, wrote a letter dated August 14, 2015 to Mukesh Sharma, principal secretary (medical, health and family welfare), expressing concerns in the manner the ‘request for proposal’ had been issued.
In his letter, he mentioned that states like Chattisgarh and Karnataka unsuccessfully launched similar schemes. He specifically mentioned that privatisation should ideally be taken up as a pilot by taking up a few PHCs, and later should be based on learnings from the pilot.
Activists say private parties are driven by profits and handing over PHCs will facilitate the development of a nexus between the private parties running the PHCs and the bigger private medical establishments in the neighbourhood.
Also, the referral of patients in the public health system operates through a chain system – from sub health centre to PHC, PHC to community health centre (CHC), CHC to district hospital and finally to medical college hospitals. This system will break after private operators come, in as they will refer patients to their own hospitals, activists have alleged. The tender document does not make it mandatory to refer patients only to public hospitals.
Moreover, the Rs 30 lakh given by the state government annually to carry out operations act as an added incentive for private operators, activists have said.
In Rajasthan, 2,211 rural and 245 urban PHCs exist. A PHC typically covers a population of 30,000 in plain areas and 20,000 in hilly, tribal or remote areas. A PHC also covers six sub-centres, the first point of contact for people in rural areas as part of the public health system network.
On July 18, 2017, the high court had directed the state to submit a status report of the PHCs operational under the PPP mode. This report is yet to be submitted. In the last hearing on October 23, the government’s lawyer submitted a compliance report to the court, but the judge made it very clear that what they want is a status report, which the government must submit at the earliest.
The next hearing is scheduled for November 23.
Rakhee Roytalukdar is a freelance journalist based in Jaipur.