Primary Health Care in Rajasthan: Experiment with PPP

While India is busy grappling with the COVID-19 pandemic, the pandemic has compelled us to acknowledge the glaring deficiencies in our public health services and infrastructure.  We are constantly faced with the vital question of affordable and accessible healthcare for all. Even though India has taken progressive steps towards achieving the goal of Universal Health Coverage through schemes like Ayushman Bharat, the state of healthcare systems remain dismal in India. This makes Primary Healthcare (PHC) in India vital, as it becomes the first point of contact between the ordinary masses and health professionals.   Heavy reliance on the primary health care system by majority Indians, in rural areas makes it an even more vital system. This is especially true in the case of Rajasthan considering 3/4ths of Rajasthan’s area is rural and thus there is heavy dependence on state healthcare systems for basic healthcare facilities. 14.7% of Rajasthan’s population also falls in the BPL category with Rajasthan also falling in the “High focus states” under National Rural Health Mission, owing to its high mortality rates.

However, the PHCs in Rajasthan  are  plagued with issues such as lack of specialists in health centers, absence of basic facilities like electricity, water supply, motor able roads, etc (See Table 1 & 2) without which some medical services cannot be delivered.

Table 1 – Infrastructural facilities in Primary Health Centers in Rajasthan (As on 31st March 2018)


Number of PHCs

Without electricity Supply (%)

Without Water Supply
(%)

Without  motor able road (%)

Without Telephone (%)

Without Computer (%)

Without Referral Transport
(%)

No. of PHCs as per IPHS norms

2078     

2.8

7.7

3.7

62.6

9%

11.5

0

Source: Ministry of Health and Family Welfare, Government of India
Table 2 – Shortfall of specialists (Surgeons, OB & GY, Physicians, Pediatricians) in Community Health Centers in Rajasthan. (As on 31st March 2018)


Required

Sanctioned

In position

Vacant

Shortfall

2352

1731

565

1166

1787

Source: Ministry of Health and Family Welfare, Government of India
This not only reduces accessibility of affordable healthcare among the masses but it also pushes individuals to rely on private healthcare that is exorbitantly priced. In a study conducted by NSSO in 2004, it was found that 28% of the rural population did not treat their illnesses or ailments due to financial constraints.

Thus, owing to these poor health indicators and lapses in the primary health care of Rajasthan, the Rajasthan Government, in a landmark reform, introduced Public-Private Partnership (PPP) in primary healthcare in Rajasthan. It was introduced under the “Run a PHC” scheme through the operations and management model, for 5 years at an annual payment of Rs.35 lakhs. The private players were to perform activities such as out and in-patient services, institutional deliveries, ante & post-natal care, laboratory investigations while the government was to provide for infrastructural and medical supplies (Rao, 2017)
The introduction of PPP made it possible for PHCs to equip with new technologies such as  glucometers, mammograms, low cost diabetes testing strips, smart-phone based hemoglobin testing, mobile laboratories and also medicine vending machines (The Economic Times, 2016). The OPD outreach  increased to  80% in six months and institutional deliveries shot up by approximately 35% (RajRas, 2016). Figure 1 below shows Rajasthan government’s evaluation of PPP model on inpatient, outpatient and institutional deliveries.

Figure 1: Rajasthan government’s evaluation of the 41 PHCs under PPP mode (As of 2016-2017)

Source: www.scroll.in  

The Government of Rajasthan reported that the Infant Mortality Rate (IMR) had reduced to 41 in 2016, as opposed to 47 in the year 2013. Similarly, maternal mortality rate (MMR) which was 255 per lakh in the year 2012 had reduced to 200 in 2016(Outlook, 2017).

However, there were some deficiencies in several PHCs owing to many reasons. The mandatory service provisions were not fully met in some of the PHCs. For example, PHCs like Achnera, Ambirama, Loondta, Kun and Savina fell short of the government mandate of 90% vaccination coverage amongst children. Pharmacies under PHCs were found stocking less number of medicines to the mandated number of medicines available through CM Nishulk Dava Yojana. Out of 241 mandatory medicines stock, these pharmacies only had stocks of around 40 to 50 medicines, which hampered the services. Many PHCs did not have basic facilities such as water, electricity, pharmacist, labor room because of which medical functions have taken a major hit. The PHCs were also plagued with private organizations recruiting under-qualified staff as a cost-cutting measure and they were found to have paid their staff a salary much lesser than in a government PHC. There were issues related to infrastructural, managerial issues too. These deficiencies have further exacerbated inaccessibility and unaffordability amongst the poor. The crux of the issue is that the annual expenses borne by private partners significantly outweigh government payouts, prompting to inferior quality services.

These issues highlighted the commercial non-viability of social sector PPPs like healthcare. Also, there was no provision for renegotiation of contracts and provision for additional payments/incentives for improved service delivery. It was a catch 22 situation for both the partners to make amendments in between. However, the PPP experiment shows improvement in certain areas and provides a scope for further improvement in PPP contract design and implementation.

Given government’s limited resources, there is an urgent need to explore areas of revenue generation and to strengthen the pre-existing public-private partnership to deliver social goods. The scope of cross-financing also needs to be explored along with an increased percentage expenditure on health to address the insufficiency of funds. Basic infrastructural facilities as well as medical expertise need upgradation to increase people’s accessibility and affordability to Primary Healthcare.  

References
Outlook. (2017, December 6). PHCs operated on PPP mode showing good results: Raj minister. Retrieved from Outlook: The News Scroll: https://www.outlookindia.com/newsscroll/phcs-operated-on-ppp-mode-showing-good-results-raj-minister/1203922
Rao, M. (2017, November 6). Ground report: Rajasthan’s privatisation experiment for public healthcare is sputtering. Retrieved from Scroll: https://scroll.in/pulse/856325/ground-report-rajasthans-privatisation-experiment-for-public-healthcare-is-sputtering
Rao, M. (2017, November 7). Rajasthan is trying to fix staff shortages at health facilities – but that’s creating other problems. Retrieved from Scroll.in: https://scroll.in/pulse/856429/rajasthan-is-trying-to-fix-staff-shortages-at-health-facilities-but-thats-creating-other-problems
Singh, J. (2018, January 9). Private concerns and Primary Woes . Retrieved from The Hindu Business Line : https://www.thehindubusinessline.com/blink/know/private-concerns-and-primary-woes/article9951293.ece#
The Economic Times. (2016, February 14). PPP in primary healthcare brings encouraging results in Rajasthan. Retrieved from The Economic Times: https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/ppp-in-primary-healthcare-brings-encouraging-results-in-rajasthan/articleshow/50980982.cms?from=mdr

Author: Prutha Pandharkame, (Intern, CIRC)

About Prutha Pandharkame (Intern, CIRC)