The Rajasthan government’s move to hand over 213 under-performing primary health centres to the private sector is resulting in more harm than a cure
At first glance, there is no water, electricity supply, toilets or waiting rooms for patients at this health facility. It has only two beds for in-patient services and no labour room. Only two laboratory tests are conducted here. No pharmacist is in sight at the pharmacy, where few medicines are to be found among the empty shelves. This is a primary health centre (PHC) in Bhanokhar, a remote village in Alwar district, but it is not a government-run facility.
The Bhanokhar PHC was among the first in Rajasthan to have its management transferred to a private party in order to function as a public-private-partnership (PPP). The condition of this PHC puts a big question mark over the State government’s ambitious plan to hand over 213 under-performing PHCs to the private sector, expecting them to improve service delivery.
The tender lists a number of services the PHC is expected to provide — outpatient services on all days, in-patient services with six beds, first aid, managing animal bites, a labour room for institutional deliveries, and ante- and postnatal care, among others. The tender also lists 15 laboratory investigations to be provided. But no laboratory can function without water, taps or sinks. Using water from a bucket, only two investigations, namely haemoglobin estimation and blood sugar, are performed at the Bhanokhar PHC. A window sill is where the tests are conducted. The PHC has been operational for two years, but villagers say there has been no improvement in services at the three-room facility.
Karma Devi, 26, delivered her second child two months ago. Living barely 300m from the PHC, she had hoped to receive medical care for her antenatal checks and during childbirth. But she received no care despite visiting the PHC early in her pregnancy and was eventually rushed to Alwar for a normal delivery.
“My labour pain started at 10 am. The doctor said they don’t have the facility even for a normal delivery. I had to go to the Government Hospital in Alwar. It took me three hours by bus and cost ₹150 one way,” said Devi, who returned to the same hospital for her baby’s first shot of immunisation. Her delivery cost her husband, Pappu Khatik, who works as a kabadiwala, several days’ wages. As she was not registered as a lactating mother at the PHC, Devi doesn’t qualify to receive ₹6,000 under the Central Government’s maternity benefit scheme.
Similarly, those in need of anti-rabies (mostly two to three children a week) or anti-venom shots (for snake or scorpion bites) do not get any treatment. Eleven-year-old Sachin Tiwari was bitten by a dog in early October. He received his first injection for rabies at the PHC. “For the remaining four injections I went to Kherli,” said Tiwari. Kherli is 17 km from Bhanokhar and has a government-run community health centre (CHC). Villagers from Bhanokhar have been going there for decades for their medical needs. The setting up of the local PHC has hardly changed anything.
“Rabies injection has to be stored in a fridge. Without electric supply, we can’t have a refrigerator here,” said a staff at the PHC on condition of anonymity. He said it affects storage and availability of many other essentials such as eye drops and vaccines for immunisation under Mission Indradhanush.
It is not just the Bhanokhar PHC which has failed to produce results. In July this year Jan Swasthya Abhiyan (JSA), a national platform for health networks in India, filed a public interest litigation (PIL) in the Rajasthan High Court challenging the rationale behind shifting from public delivery of services to PPP mode in primary healthcare. Among the major assertions of the PIL is that the PPP mode does not ensure better services; in fact they deteriorate in most cases due to the commercial interest of the private player. An assessment by the petitioners of 30 out of 41 PHCs shows that services are not satisfactory in most. Lack of childbirth facilities is common, be it at the Sonad PHC in Dausa district or Richha in Dungarpur. So is the absence of essential medicines. Pharmacies at the PHCs are mandated to have 241 medicines listed under the Mukhya Mantri Nishulk Dava Yojana. Some PHCs were found to have barely 39 medicines. The Bhanokhar PHC has 50-odd medicines on any given day, according to the staff. Lack of refrigerators and drinking water emerged as other crucial issues.
A business model?
The “Run a PHC Scheme” was introduced in Rajasthan through a short-term e-tender notice dated December 28, 2015. The government claimed that it was seeking the assistance of the private sector “to improve the availability and quality of primary healthcare services towards meeting the state, national and Millennium Development Goals.” It is to be noted that MDGs had already been replaced by new targets of Sustainable Development Goals. But there are other reasons too, including financial considerations, for the shift to PPP mode.
“Rajasthan is a big State and manpower is short. It is not possible for the government to run all the PHCs. There is a high rate of absenteeism of doctors in remote areas. In addition, the structure in the government sector is rigid where, without the entire paraphernalia, nothing can be established. Private sector, on the other hand, is flexible and can function without fulfilling all the laid-down details,” said Naveen Jain, mission director, National Health Mission, Rajasthan health department. He added that the government’s expenditure is less in a PPP compared to its own PHCs. “If we can get the same services in less amount, then why not?” he asked.
The government pays a maximum of ₹30 lakh a year — or ₹2.5 lakh a month — to private bidders for each PHC. The tender finally goes to the lowest bidder, who files for an amount lower than the maximum limit. Norang Ram Dayanand Dhukia Shikshan Sansthan won the bid for Luna PHC in Jhunjhunu for only ₹1.49 lakh a month. As many as 14 PHCs are running on less than ₹2 lakh a month.
“A government PHC needs around ₹4-5 lakh a month. The cost of a PHC increases with the seniority of the staff because their salaries increase. This is not the case while giving out a PHC in PPP. We quote an amount according to the salaries of the junior-most staff. It depends on the private partner to divide it among them,” said RN Meena, joint director in the Rajasthan health department. The current model aims at providing services by spending less, but that clearly comes at the cost of quality. “The PHCs are already operating at minimal cost. Lowering it further will only mean compromise on quality,” said Dr Narendra Gupta, convenor, JSA.
The current model has given rise to many unfair practices. For example, the bid for the Bhanokhar PHC was won by a Dhaulpur-based St Conard Shiksha Samiti. It has subcontracted it to Kherli-based Hariom Khatara and his partner Amar Singh Dhakad. This arrangement is against the terms of the tender, which requires the bidder to run the PHC directly. Of the 11 staff members, three, including the pharmacist, work at the contractors’ office in Kherli. In effect, while they draw salaries from the PHC, they don’t work there.
Evidence from other States
Experiences for PPP in primary healthcare in other States are not encouraging either. Karnataka started the Arogya Bandhu Scheme (ABS) in 2008 for 56 PHCs. However, an evaluation by the Institute of Health Management and Research in 2015 showed that the shortage of human resources as well as equipment at the PHCs continued. While all medical officers in government PHCs were MBBS doctors, nearly 20 per cent of them in ABS PHCs were non-allopathic doctors. Subsequently, the government wound up the scheme and took all PHCs back into its fold.
Similarly, the Uttarakhand government launched its PPP scheme for community health centres (CHCs) in May 2013. By late 2014, complaints of overcharging and overdiagnosis started to flow in. By December 2015, all 12 contracts were terminated. The matter is pending before the Uttarakhand High Court.
A recent evaluation report by the health department in Rajasthan, however, projects good results. According to the findings, footfall in OPDs has doubled in the last 13 months, and quadrupled in IPDs. Institutional deliveries have also gone up. But the data has been questioned by health activists.
A report by Gopal Verma, who assessed the Bhanokhar PHC for JSA, showed that the PHC’s footfall has declined in the last two years. While between June and August 2016, nearly 2,500 people visited the OPD, the number dropped to 1,300 in 2017 during the same period. The evaluation has been made on three out of 11 parameters. “These are the major indicators. OPD, IPD and institutional deliveries are linked to all the other services and it is enough to evaluate them,” said Meena.
But Gupta disagrees. “They have reduced a PHC to only curative aspect. But primary healthcare is about prevention and promotion of good health too. Other parameters include school health check-ups and family planning methods. How can they be evaluated through OPD footfall?” he asked.
Confusion at the highest level
It seems that the Central government is yet to make up its mind about PPP. In 2015, CK Mishra, the then health secretary of Government of India, wrote to the Rajasthan government to re-evaluate the scheme. His letter flagged concerns such as exclusion of non-communicable diseases, and the lack of preventive care and a referral system. The letter said that PPP should not be adopted for all PHCs, in order to prevent a collapse of primary healthcare.
The National Health Policy 2017, on the other hand, emphasises on collaboration with the private sector for primary healthcare. It suggests exploring collaboration for primary care services where critical gaps exist. It further says that the private sector can be engaged for preventive or promotive services on contractual terms with the government. It includes initiatives under corporate social responsibility.
Niti Ayog, too, has begun a push towards a PPP model in district hospitals. However, in the light of the ground-level experiences, the policy needs a rethink. The government will have to do away with the model of lowest bidder and instead go with one that focuses on a rational utilisation of funds.