Ill-planned, ill-executed PPP projects behind Uttarakhand’s crumbling health services

Sources: citizenmatters.in

Dehradun’s biggest government-run medical college and hospital is the Government Doon Medical College Hospital (GDMCH). It caters to a population of over 10 lakh apart from patients referred from hilly areas. But one can deduce the state of the most basic amenities in the GDMCH when one hears that a 27-year-old pregnant woman gave birth to a child on the floor in the hospital corridor. Hailing from Chinyalisaur village (Uttarkashi district), both woman and child died in the incident reported last September. Citizens rallied and protested against the hospital authorities, but nothing changed. This, in fact, is a telling depiction of the shambles in which the health sector in the entire state of Uttarakhand is in.

Dropping two places as compared to last year in Niti Aayog’s Health Index, Uttarakhand’s 17^th place indicates the severe lacunae in almost all the 23 health indicators used to prepare the index. Lack of doctors and specialists, inaccessibility due to geographical proximity, inadequate medical infrastructure to carry out basic diagnosis are some of the main reasons for the state’s dismal performance.

Niti Aayog, releases three indexes every year (Education, Water and Health) to rank states based on a number of parameters to help them formulate action plans and policy roadmaps to improve performance. Last year, the Himalayan state secured 15th rank with 45 points but this year it scored just 40 points. Also, as per the data presented by State’s Migration Commission, 8% of the migration taking place in villages is due to inadequate health services. In the last seven years, 700 villages have been completely depopulated. The commission estimates that around 1,18,981 people have permanently migrated from their villages.

The state’s poor healthcare infrastructure is to a great extent due to the administration’s huge preference for large scale Public Private Partnership (PPP) projects which are being executed in an ill-planned and hasty manner. Absence of robust monitoring and regulation mechanism makes PPP a lethal combo, making citizens vulnerable to inefficient health delivery services.

The state government had framed a Uttarakhand Policy on PPP in 2012, which included in its ambit not just health but also urban infrastructure, energy, agriculture and tourism, which were identified as priority areas. To anchor, incubate and execute all PPP projects, the government created a specialized nodal agency, Uttarakhand Public Private Partnership Cell (UPPPC). The Asian Development Bank (ADB) played a crucial role in the instrumentalisation of these PPP projects as also in the setting up of UPPPC and its technical secretariat.

Since the creation of UPPPC, a total of 75 PPP projects (worth Rs. 6382.78 cr.) were identified for implementation out of which only nine projects (12%) are functional on the ground today, with 13 projects (18%) at implementation stage, 20 projects (27%) at the bidding stage and the remaining 33 projects (44%) yet to get started, as per the data available on the UPPPC dashboard.

By and large, independent experts and citizens are supposed to scrutinise the PPP projects in various sectors. For instance, the state solid waste management plant at Shishambada developed by the state government in PPP mode has faced intense opposition from local residents. Also, the door to door collection services by Dehradun Municipal Corporation under the PPP mode is receiving poor response from citizens.

Coming back to the health sector in particular, lack of health care professionals, concentration of doctors in a few urban hubs like Dehradun, Haldwani etc, inefficiency in service delivery and inaccessibility are some of the major issues, says a UPPPC report.

To overcome the gaps in service delivery, the government decided to implement PPP-based projects, handing over five government hospitals to private parties. Tehri is today the leading district in PPP-based health projects, with the district hospital and the Combined Health Centres (CHCs) now both being run by private companies, as are CHCs (and Coronation Hospital) in Dehradun, Devprayag and Baleshwar. The conversion of CHCs in Almora and Nainital to PPP mode is also under consideration.

Ailing health services in Devbhumi  

Health services in Uttarakhand have long been under the scanner for various reasons. Niti Aayog’s Health Index red flagged several parameters, especially infant mortality rate, sex ratio and neo-natal mortality rate. In terms of institutional deliveries, the state was ranked 18th. Shockingly, Uttarakhand is the only state to have registered an increase in the rate of neo-natal mortality, and ranked a poor 19 on sex ratio.

The findings of the index have found substance in recent incidents reported across various health centres. Take the Dehradun case for example. The change in administrative control of GDMCH from the health ministry to the education department has resulted  in chaos due to dearth of doctors, funding issues and a critical shortage of beds (it currently has 300 beds) with reports that patients have been treated on stretchers.

“PPP has been a mixed bag of successes and failures,” said Dr Lalit Mohan Upreti, Former (Retd.) Director, Medical Health, “It has played a significant role in addressing some of the most chronic issues plaguing the healthcare sector in Uttarakhand. Initiatives like deploying domain specialists, developing ICU capabilities, providing basic health infra in rural areas, are some of the positive examples to showcase. Some health care facilities like in Tehri and Dehradun are functioning better than before.”

However, Dr Upreti also alluded to certain defects in the model. “Loose MOU format, non-clarity in terms and conditions and absence of a monitoring framework are some key issues. Organisations partnering with the government are largely driven by profit motive which is undermining the service delivery process. Setting up of an independent monitoring mechanism can boost the performance of the state’s PPP based healthcare projects,” he said.

The state also introduced a new health policy, Atal Ayushman Uttarakhand Yojana (under the aegis of Modicare), aimed at providing health coverage of upto Rs 5 lakh to more than 18 lakh families at primary health centres, district hospitals or empanelled private hospitals (after being referred by government hospital). But the policy ran into a web of irregularities.

As per a report  in Hindu Business Line, 657 complaints of non-implementation have been filed till June 2019 by the state health department and have been reported to the Uttarakhand’s National Health Authority which has forward the report to the Union Health Minister. Some of these amount to criminal offences, as FIRs have been lodged with the police by the state health department.

Eleven hospitals have been fined Rs 1.17 crore. Sri Mahant Indresh Hospital, one of the biggest privately operated hospitals in Dehradun, has been served a notice of recovery of Rs 11.82 lakh. Some hospitals have paid the fine, while with others, the process of recovery has been initiated. Under the Atal Ayushman policy, private hospitals are empanelled to government hospitals and health centres can refer cases that they are not equipped to treat.

The policy details certain packages to cover the costs incurred by the private hospital for treatment of these patients, which the State Health Agency is supposed to settle within 15 days.

Failing emergency services

Another casualty of the new policy is the degradation of service delivery of the 108 emergency ambulance service, once known as the state’s health lifeline. It was earlier managed by the government in PPP mode with a private firm, GVK EMRI. The agreement was originally for ten years. But as the government failed to find a new operator before the term expired, GVK EMRI was twice given an extension of six months.

Amidst several issues such as delay in payment of salaries to employees and charges to operator and the uncertain future of contractual employees, an agreement was finally signed with a new operator company, Community Action and Motivation Programme (CAMP).

Today, CAMP operates around 70 ambulances in the state, as against the 140 odd that GVK EMRI used to operate. A few of CAMP’s ambulances met with accidents recently, mainly because the new operator had no prior experience in carrying out such emergency and relief operations in hilly terrain. Not only this, the poor upkeep of ambulances has resulted in deaths of people needing urgent health support. Last October, a youngster in Berinag (160 kms from Nainital) lost his life because 108 could not reach on time due to unavailability of diesel for the ambulance.

“Emergency services like 108 have been a blessing for Uttarakhand”, said Anoop Nautiyal, Former CEO, 108 Emergency Services. “The state has major accessibility issues given its geography and terrain. To address these, initiatives like 108 are necessary. PPP has been a positive step towards strengthening the health sector. However, due to the absence of a strong monitoring mechanism there is a major mismatch between the PPP potential and actual on-ground results.”

What’s next?

While the incumbent BJP government under Chief Minister Trivendra Singh Rawat is rooting mightily for PPP in health care, the sick are not seeing any actual benefits on the ground. In fact, health centres in rural areas seem to have become nothing more than referral points to private hospitals located mainly in urbanised parts of the state, which also puts a lot of pressure on the latter. And with development focussed on urban centres, health centres in rural areas are being denied adequate financial, technical and manpower resources.

Apart from recruitment initiatives to tackle the increasing number of vacant positions (it is estimated that only 1200 of the 2700 vacant posts have been filled), especially the dire need of experts (radiologist, cardiologist, etc), there is little thought given to deployment of preliminary or basic diagnosis mechanisms and equipment for basic health check ups in rural areas.

The Uttarakhand High Court in the landmark case of Chandra Shekhar Joshi v State of Uttarakhand in 2015 had issued a set of directions to be followed by the state government to create a robust network of government hospitals. The directions issued in the judgment should be revisited and progress of the same should be tracked.

Though the government is pursuing aggressive health reform at the policy level, more needs to be done in consultation with domain experts and citizens. One of the most critical steps for the state would be to create penal provisions for addressing corruption among medical practitioners and administrators.