Ground report: Rajasthan’s privatisation experiment for public healthcare is sputtering

The primary health centre in Achnera village in Pratapgarh district of Rajasthan has not had a doctor for three months. Sitting at a tea stall with other residents of the village one day in early October, farmer Kanhaiyalal Kumavat said, “This is a hospital only in name.”

The Achnera primary health centre or PHC is one of 41 PHCs across 18 districts that the Rajasthan health department handed over to private parties last year to manage under a public private partnership. The Achnera PHC is now run by the Chitransh Education and Welfare Society, a non-profit organisation.

Kumavat and others at the tea stall that day said that before Chitransh took over, doctors would be available at the PHC at all times of day and night. Now, Achnera sarpanch Kanhaiyalal Meena has written a letter to Rajasthan’s chief minister asking for the government to reclaim the PHC.

Earlier this year, the state conducted an evaluation of the partnership programme under which Chitransh was running the Achnera facility and declared it a success. However, the evaluation has been conducted on only three of 16 parameters.

The programme started in December 2015, when the Rajasthan government opened bids to private parties, both non-profit and for-profit organisations, to run all 213 of the state’s PHCs. The terms of the public private partnership agreement state that the government would pay the private party between Rs 22 lakh and 35 lakh, depending on the bids received, to run a PHC for five years. After evaluating the private organisation’s performance, the contract could be extended beyond five years.

The private organisation is expected to employ at least 11 staff members including a doctor, a pharmacist, laboratory technicians and cleaners. Even Auxiliary Nurse Midwives who manage health sub-centres and have so far been employed by the government are transferred to or hired by the private organisation. The government’s contribution to the partnership is infrastructure – the building, medicines, and equipment like surgical supplies and laboratory reagents.

To assess the government’s claims about the success of the programme, Scroll.in visited five PHCs run by the private providers and found mixed reports of their performances from residents using the facilities. While in some villages, the people were satisfied with services provided, in others people were distrustful of the privately-run PHCs.

Faulty evaluation

The Rajasthan government’s evaluation report of the 41 PHCs details the footfall in outpatient departments and in-patient departments as well as the number of deliveries both one year before and one year after the change in management. The report states that there has been almost double the number of outpatients, almost four times as many in-patients and twice as many women delivering babies across the PHCs.

The report does not contain evaluations of vaccination rates, use of contraception, antenatal check-ups or screening of malnourished children. The public private partnership contracts list 16 evaluation parameters:

• Out patient numbers
• In patient numbers
• Registration of pregnant women 
• Number of pregnant women who get all four antenatal check-ups
• Normal child deliveries
• Referrals of high risk pregnancies
• Whether infants at higher risk of dying are identified and referred
• Whether malnourished children identified and referred
• Number of children fully immunised
• Sterilisation rates 
• Temporary sterilisation methods recommended
• Laboratory tests performed 
• On-time submission of medical records
• Death audit reports
• Attendance in monthly monitoring meetings 
• School health check-ups

Moreover, there is uneven progress even in the three parameters evaluated. For example, no children have been delivered in five of the 41 PHCs. Only four PHCs conducted more than 200 institutional deliveries in the past year – a target that has been set in the public private partnership agreement.

A PHC is the first point of contact with a public sector doctor, especially in villages across India, and typically serves about 30,000 people. The bulk of the healthcare work that a PHC conducts is preventive – vaccination drives, conducting antenatal check ups, screening for diseases like malaria and tuberculosis, and implementing other government health programmes.

Public health specialists in Rajasthan say that the PHCs now managed by private organisations may work well on curative healthcare, but do not implement preventive and promotive health measures. This means that these centres are little more than clinics.

Scroll.in visited five villages with privately-managed PHCs in October – Achnera and Ambirama in Pratapgarh district, and Loondta, Kun and Savina in Udaipur district – where vaccination rates fell short of the government-mandated target of having 90% of all children fully immunised.

Scroll.in could not verify what the vaccination rates in these areas were since the state has not provided details.

“It is impossible to evaluate based on government figures if the vaccination rates have increased, for instance,” said Dr Narendra Gupta from the Jan Swasthya Abhiyan, a network of health advocacy organisations that works in several states including Rajasthan. “These figures have been routinely fudged everywhere. We need an independent third party evaluation to understand if there is any improvement in the figures.”

Who is running PHCs?

Among the private parties running the 41 PHCs are WISH Foundation, a non-government organisation that works on innovation in healthcare technology, and Vani Sansthan, a non-governmental organisation that works on health rights. Others include medical or nursing colleges such as Geetanjali Medical College and Hospital, Udaipur and private hospitals. Some organisations like Chitransh Education and Welfare Society have no experience running a healthcare facility. Chitransh has runs a small school in Jaipur and claims to have conducted training programmes for health workers.

Health experts in Rajasthan are also concerned that the programme is being implemented on a large scale without a test run.

In 2015, when the Rajasthan government had drawn up the public private partnership plan and before it started the bidding process, the union health ministry recommended that the state would need to run a pilot in five or 10 PHCs and get an independent evaluation before scaling up the model. This was not done.

In 2016, the Jan Swasthya Abhiyan filed a public interest litigation at the Rajasthan High Court alleging that the public private partnership model would destroy the public health system as it would break the established chain of referral – from primary health centre to district hospitals at the secondary level to medical colleges at the tertiary level.

The petition states that the money offered to run these PHCs was “ridiculously minuscule” and that the conditions of the public private partnership agreement would only be acceptable only to private bodies who “have the motive of earning profits” from the arrangement.

But all the private organisations partnering with the Rajasthan health department that Scroll.in spoke to claimed that their motive to enter this scheme was social service.

The Jan Swasthya Abhiyan petition also asked for independent evaluation and monitoring of the programme.

The Rajasthan government has still not commissioned an independent evaluation. Instead, in addition to the 41 PHCs already being privately managed, the state handed 57 more urban and rural PHCs over to private organisations in 2017.

The non profit organisation Prayas, which is not a partner in the scheme, conducted a fact finding exercise at 25 privately-run PHCs to get a sense of how they function. “While some health facilities were found to be in a relatively better state in comparison to others, some were much below the standard,” said Chhaya Pachauli from Prayas. “None of the health facilities was found to be doing outstandingly well in comparison to those being directly operated by the government.”

She added that PHCs that are still being run by the government but have been upgraded and categorised as Adarsh (meaning ideal) PHCs function much better than the privately-run PHCs.

What PHC users say

Loondta village got a primary health centre five years ago. However, the facility began admitting women for childbirth only four months ago. This is because the PHC, which has been handed over to Geetanjali Medical College and Hospital, now has a a full-time doctor and public health worker called a Lady Health Visitor who delivers babies. But residents of Loondta still say services at the PHC should be better.

Residents of Kun village have been vehemently against the privatisation of their PHC. Their main complaint is that the doctor is hard of hearing and they do not trust him. They feel forced to go to larger health facilities even for small ailments. But these larger hospitals are much further away.

“We do not want to travel to the community health centre in Bhinder block [about 30 kms away] for small ailments like fever,” said Vipul Jain, who runs a shop selling groceries.

What was common in the PHCs that Scroll.in visited is that residents for whom the facilities are meant preferred other nearby government-run institutions, sometimes other PHCs.

In Kun and Loondta village, the people from the village claimed that the doctors were referring patients with more serious illnesses to the private Geetanjali Hospital, instead of to a government-run community health centre or district hospital. Omi Singh, who manages PHCs for Geetanjali Hospital, has denied this allegation.

Little accountability

A big problem Rajasthan’s public private partnership model of running PHCs is the lack of a grievance redressal system built into the contract.

Sub-district health officers are not clear on what kind of action they can take against private managements in case they fail to deliver requisite health services.

“I have the right to remove or complain against health staffers [employed by the government] if they do not work well,” said Dr Narendra Verma, medical health officer for Arnod block in Pratapgarh district. “What is the liability of the private provider? What kind of action can I take?”

People using the PHCs also said they did not know how to report complaints.

“I tried to lodge a complaint,” said Mahavir Jain who runs a shop at Kun and tried to call Geetanjali Hospital on its landline about the lack of facilities like instruments to check blood pressure. Jain also wanted to complain about the doctor’s incompetence. But he could only speak to a phone operator at the hospital.

“I do not know what has become of the complaint still,” he said. “If we have our own PHC, at least we know who to complain to.”

Earlier, the residents of Kun knew that in case there was a problem at the government-run PHC, they could go to their local elected representatives like the sarpanch.

The government claims to be aware of complaints against the privately-run PHCs. Dr RN Meena, joint director of hospital administration in Rajasthan, said that the government has cancelled its contracts with four PHCs based on complaints and has once again taken over running them.

Preventive healthcare takes a back seat

Before the Rajasthan government decided to implement the public private partnership model, they had been warned about possible pitfalls.

In August 2015, CK Mishra who was then the union health secretary expressed concerns about the model. Mishra said that the union government’s policy is to help states strengthen primary health care and that health services should be contracted out only as temporary measures.

The National Health Systems Resource Centre, a technical body attached to the National Health Mission, also evaluated the Request of Proposal prepared by the state to invite bids for managing PHCs. They said that the package of services envisaged in the proposal are limited to reproductive and child health and there is no clear articulation of the other services in the state and national health programmes such as management of communicable and noncommunicable diseases. The body recommended that the model should be piloted in five to 10 PHCs before it is scaled up.

India’s biggest public private partnership healthcare experiment has been Karnataka’s Arogya Bandhu Scheme launched in 2008. The scheme allows non-government organisations, medical colleges, and philanthropic organisations to help run PHCs. An evaluation in 2016 showed that there was not much difference between the PHCs run by the government, and those run by private parties. Karnataka’s privately-run PHCs also did not properly implement immunisation and antenatal services.

Dr T Sundararaman, dean of the School of Health Systems at the Tata Institute of Social Sciences in Mumbai, said that the public private partnership model aims to fulfill the function of a dispensary, which only takes care of curative aspects of medicine. The model does not even account for some very important functions of primary health care such as basic vector control activities or disease surveillance.

“The private institution is good at giving clinical services and there is an improvement in the services at the institution,” said Dr Sanjeev Tank, chief medical and health officer in Udaipur district. “But the services in the field and the preventive services have to be improved. The private partners are not oriented towards field realities. It will take time.”

Despite this, the Rajasthan government did not consider evaluating the privately-run PHCs performance on these crucial measures of primary health care.

Instead, said RN Meena dismissed the larger concerns around privately-run PHCs. “It takes a little time for the staff to develop trust in the village, especially for immunisation and family welfare activities,” he said. “These are minor issues.”