A bitter pill for Rajasthan's ailing health care

But outsourcing health care offers a prescription for hope to the state's population of 70 million

Against the will of her own party members and activists, the Vasundhara Raje-led Rajasthan government had announced its intention to outsource health services to private entities last month. Raje's decision to open the health sector to private-public partnership (PPP) in rural areas follows a series of industrial reforms since she took over in December 2013.

She has earned scathing criticism for her government's actions, but the doughty two-time chief minister is gung-ho about opening more sectors such as education, tourism, power and transport to private entities. Raje had told Business Standard in a rare interview last year that her government was groaning under a cash crunch because of the policies of the previous Congress government. She said PPP was the only way to take the state forward. (WHAT’S THE PROGNOSIS?)

To begin with, her government is inviting tenders to outsource 90 primary health centres (PHCs) in rural areas. The requests for proposals (RFPs) are out for setting up specialised centres for magnetic resonance imaging (MRI), CT scan, oncology, dialysis and in-vitro fertilisation at all the 34 district hospitals across the state.

The terms of the PPP engagement are simple. While the state government will provide the necessary infrastructure, medicines, equipment, and operational costs, the private sector will hire staff and manage the government's PHCs, and special centres.

"But these 90 PHCs are functional only on paper. We are finding it inconvenient because of shortage of medical staff. We decided to outsource after some non-profit organisations showed interest," Rajasthan's Health Minister Rajendra Singh Rathore told Business Standard.

But, can the private enterprises/non-profit organisations ensure medical staff and facilities at these far-flung PHCs when the state, with all its resources, could not? There is also the question of credibility of the private partners.

Himani Sethi, head of programme at Wish Foundation, says finding qualified medical practitioners for rural PHCs is a challenge on many levels. "We are trying to bring fresh medical graduates and retired government doctors, who will be provided training on primary health care and non-communicable diseases (NCDs)," she says.

"To build accountability among the staff, we are working with the government to develop an output and outcome-based incentive system. We are advertising, and are looking for doctors from other states such as Bihar and Madhya Pradesh," she says.

The Wish Foundation has taken the responsibility of operating 30 PHCs and 170 sub-centres on PPP mode in the 12 districts of Rajasthan. This is besides the 90 PHCs the government is planning to give to other organistions.

Take a turn for the worse

Rathore and Sethi's explanation to outsource health care, however, has not gone down well with the local non-profit organisations and political parties. The previous Ashok Gehlot-led Congress government, too, had rejected the idea of PPP in health care.

Anti-PPP activists allege that the current Bharatiya Janata Party (BJP) dispensation has abdicated its primary responsibility of providing basic health care. The state has not taken cue from other states, especially Uttarakhand and Karnataka, where private partners abandoned the PHCs midway, after finding them financially untenable.

In Rajasthan, the state government spends Rs 32 lakh per annum on each PHC. It will award contracts to those who bid to operate PHCs below Rs 32 lakh.

"It is a scam," alleges Chhaya Pachuali of Jan Swasthya Abhiyan, a non-profit organisation, adding, "The private bodies are driven by greed with little or no regard for the public health system. With eye on bottomline, they would either compromise on the quality of health care services or get into irrational treatment practices."

Activists say there is no guarantee whether these private doctors would implement the various government schemes offered gratis like child vaccination, parturition, and 15 other medical tests.

A senior government official, who is involved in this project, says plenty of groups are showing interest in running a PHC. The PHCs will give them the opportunity to tap a rural market at the cost of the public exchequer. The doctors at the centres can refer patients to their respective private hospitals for secondary or tertiary treatments, whereas the medical colleges will get a chance to increase the number of seats by treating more patients.

The officials suggest the pending launch of Chief Minister Raje's ambitious Bhamashah Insurance scheme will further benefit the private entities. Though the contours of this insurance scheme, which will cover nearly 66 per cent of the state population, are yet to be made public, it is likely that the state government will bear the cost of the insurance premium. "A citizen with state insurance will prefer treatment at a private hospital, referred to him by a doctor at the PHC," says an official, on condition of anonymity.

Dream run over

The government's move, which many say was under consideration for the last one year, has stoked fear among nurses, midwives, pharmacists and lab technicians, who were waiting to join the government services after completion of their respective medical courses. They admit there is a shortage of doctors at the PHCs, but there is no dearth of nurses, midwives, pharmacists, and lab technicians, who are more than willing to join. A PHC has a staff strength of 11, including a doctor.

"Our dream of a government job seems to be over now," says Praveen Kumar Sen, a pharmacist and one of the agitating leaders. "Today the government is outsourcing the work of PHCs to private people; tomorrow it will not fight shy of giving the community health centres and district hospitals to corporate houses," says Gulab Chaudhary, a third-year nursing student in Jaipur.

According to rough estimates, around 30,000-40,000 students pass out every year from nursing, medical and pharmacy colleges in the hope of lucrative government jobs.

"Ironically a government peon with no degree earns around Rs 25,000 a month, whereas we have a specialised degree and are offered Rs 8,500 per month by the contractors," rues Bharat Beniwal, a student leader of the Rajasthan Medical Association.

A top government official says if the government implements the scheme in right earnest, it will benefit a population of 70 million in the state. Otherwise the government would be inviting only vultures to prey on public money.