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Whose Public Action?
Analysing Inter-sectoral Collaboration for Service Delivery
KARUNA TRUST AND DEPARTMENT OF HEALTH AND
FAMILY WELFARE GOVERNMENT OF KARNATAKA:
MANAGEMENT OF PRIMARY HEALTH CARE CENTRES
Padmaja Nair
Lucknow, India
Published: July 2008
(c) International Development Department (IDD) / Padmaja Nair
ISBN: 0704426730
9780704426733
E-S-R-C
ECONOMIC
& S O CIA L
RESEARCH
COUNC I L
UNIVERSITY017
BIRMINGHAM
This research is funded by the Economic and Social Research Council under the ESRC NonGovemmental Public Action Programme. The ESRC is the UK’s leading research and
training agency addressing economic and social concerns. ESRC aims to provide highquality research on issues of importance to business, the public sector and Government.
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CONTENTS
ACRONYMS
SUMMARY
1. BACKGROUND AND METHODOLOGY
1.1 Research Agenda
1.2 Methodology
2. ORGANISATIONS IN THE RELATIONSHIP
2.1 Kanina Trust
2.1.1 Origin and features of public action
2.1.2 Vision and purpose
2.1.3 Activities
2.1.4 Organisational structure and management
2.2 Department of Health and Family Welfare
2.2.1. Health care and systems in Karnataka: the context
2.2.2. Public action
2.2.3 Organisational structure and management
2.3 Positioning of the Trust and DH&FW within the sector
3. CONDITIONING FACTORS
3.1 Policies of the Central Government shape programmes and structure
3.2 Task Force on Health and Family Welfare and Integrated Health
Policy
3.3 Externally aided programmes
3.4 Influence of the tribal culture on the Trust
4. SHAI-----4.1 Gro
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4
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4.2 Pen
—mip
''e Trust and DH&FW
'sy Control Programme
District: widening scope of
snship
2
4.2.1 NGO’s perception: support and effectively utilise government
resources
4.2.2. For DH&FW partnership is a matter of convenience...
4.3 Formal rules and contracts
4.3.1 PHC Handing Over Project: Based on Government Order
4.3.2 Scheme for involving private medical colleges and other agencies
in the management of PHCs: Scheme document and contract
5. THE RELATIONSHIP IN PRACTICE
5.1 Operation of the relationship
5.1.1 At the State level
5.1.2 At the operational level
6. EFFECTS OF THE RELATIONSHIP
6.1 Effect on the partner organisations
6.2 Effect on the agenda
7. CONCLUSIONS
List of Interviewees
References
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ACRONYMS
ANM
BHO
CHC
DH&FW
DHO
FCRA
GP
GoK
IPP IX
ISRO
MCI
MO
NGO
NSP
OT
PHC
PHU
PPP
RCH
THO
VGKK
WNL
WHO
ZP
AUXILARY NURSING MID-WIVES
BLOCK HEALTH OFFICER
COMMUNITY HEALTH CARE CENTRES
DIRECTORATE OF HEALTH & FAMILY WELFARE
DISTRICT HEALTH OFFICER
FOREIGN CURRENCY REGULATION ACT
GRAM PANCHAYAT
GOVERNMENT OF KARNATAKA
INDIA POPULATION PROGRAMME IX
INDIAN SPACE RESEARCH ORGANSIATION
MEDICAL COUNCIL OF INDIA
MEDICAL OFFICER
NON GOVERNMENT ORGANSIATION
NON- STATE PROVIDERS
OPERATION THEATER
PRIMARY HEALTH CARE
PRIMARY HEALTH UNIT
PUBLIC- PRIVATE PARTICIPATION
REPRODUCTIVE & CHILD HEALTH
TALUKA HEALTH OFFICER
VIVEKANADA GIRIJAN KALYAN KENDRA
VISWESWARAYYA VIDYUT NIGAM LIMITED
WORLD HEALTH ORGANISATION
ZILLA PANCHAYAT
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KARUNA TRUST AND DEPARTMENT OF HEALTH AND
FAMILY WELFARE GOVERNMENT OF KARNATAKA:
MANAGEMENT OF PRIMARY HEALTH CARE CENTRES
SUMMARY
This case study focuses on the relationship between Karuna Trust, a Bangalore
based NGO, and the Department of Health and Family Welfare, Government of
Karnataka. Karuna Trust has been almost exclusively working in the health care
sector for the past two decades, with primary heath care as its core function. Over
the years other related programmes like education and community development
were integrated into the portfolio of Karuna Trust, although health continues to be the
centre of focus. This report looks at the relationship between Karuna Trust and the
Department of Health and Family Welfare through a partnership programme, wherein
the former manages a selected list of government Primary Health-Care Centres
(PHCs) in the State. A pioneer in the area, especially on a relatively wide scale, the
model is attracting interest in some other States in the country.
1. BACKGROUND AND METHODOLOGY
1.1 Research Agenda
This case study is part of a larger study on non-govemment public action and the
relationship between the state and non-state providers (NSPs). The core argument of
the research is that the government and NSPs involved in the delivery of specific
services are conditioned by their respective organizational and institutional structure
and policies. This in turn may lead to tensions over the very purpose and process of
‘public action.’ Further, the research hypothesizes that they manner in which the
relationship is formally and informally organized also affects the capacity of partners
to influence and control the service delivery agenda and process. Three service
delivery sectors were identified for the research: sanitation, education and health
sectors.
1.2 Methodology
The whole research project was undertaken in stages over a period of two and a half
years and included (i) a scoping study to trace the evolution of the sector and identify
the key policies and programmes; (ii) selection of a specific programme within each
sector through which the core research issues were to be studied; and (iii) finally
identifying cases to analyse relationships in more depth. In the health sector. Primary
Health Care was identified as the programme which offered most scope to examine
the dynamics of the state-NGO relationship. Karuna Trust in turn was identified for
the case study because this was the only case of an NGO managing several PHCs
over a period.
Like, the other case studies in the project, field work and data collection stretched
over a 10 months and involved three rounds of visits to the project sites and
interactions with a range of stakeholders at the state, district and gram panchayat
(rural local council) (GP) level as well as the three tiers of the Primary Health Care
structure in the state. Apart from interviews with the director and staff of Karuna
Trust, the limited documents available were reviewed to construct the evolution of the
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NGO, especially in relation to its involvement with the state. Interviews were also
held with senior officials from DH&FW to understand the state perspective and policy
on health care at large and on partnership in particular. The researcher thereafter
visited a number of PHCs and Sub-Centres managed in partnership with Karuna
Trust and interviewed the staff employed by Karuna Trust as well as the concerned
government staff at block and district level who are directly responsible for monitoring
and managing the performance of Karuna Trust as well as providing necessary
support. This included the Block Health Officer (BHO) and the District Health Officer
(DHO) and their respective teams. An in depth understanding of the functioning of
the elaborate three- tier health care structure in the state was obtained. The
researcher also interacted with some members of the community and community
representatives at the GP and block levels.
2. ORGANISATIONS IN THE RELATIONSHIP
This section attempts to build a profile of the two partner organizations in terms of
their vision and consequent approach to health care delivery. In the process it
describes their separate goals and missions as well as their activities, organizational
structure and functions. The profile itself is drawn with the purpose of locating the
two partners in relations to the partnership and understanding the synergies
generated.
2.2 Kanina Trust
2.2.1 Origin and features of public action
Karuna Trust (henceforth referred to us the Trust), was established as a public
charitable Trust in 1986 and an affiliate organisation of the Vivekanada Girijan Kalyan
Kendra (VGKK) in B.R. Hills, a sub region in the State of Karnataka. VGKK itself was
founded earlier in 1981 by a medical practitioner. Dr. H Sudarshan, who, concerned
about the plight of the predominantly tribal (Soliga) population of this very backward
area, had initiated basic health care programmes here. Although, initially Sudarshan
managed the activities on his own, he was soon joined by a small team of dedicated
and like minded people, some of whom were natives of the region.
While working in the regions, the founder discovered that leprosy was prevalent
amongst the tribals, who in reality contracted it from the non- tribals in the area. As
the disease was ‘hyper endemic’ in the region and the situation was alarming, calling
for urgent and focused action, a separate (Karuna)Trust was set up by Sudarshan to
address the problem and to bring the non tribals within the scope of the interventions.
Sudarshan (henceforth referred to as ‘director of the Trust’) decided that a separate
organization was necessary because VGKK itself was committed to working
exclusively with the tribals. By 1990 the Trust had covered substantial ground under
the Leprosy programme and hence turned its attention to other health issues. Over
the next few years it expanded both in terms of geographical coverage as well as
health issues to include, control of TB, eye care, dental health, mental health, RCH,
etc. Subsequently, towards the later half of the 1990s (1996) the Trust developed its
signature approach to primary health care through the structure of the PHCs. The
health and community-based rehabilitation programmes subsequently became part
of a broad set of socio-economic activities.
By 1996 the Trust, spread rapidly to cover 59 villages in Yallandur Taluk1
(Chamrajnagar District) and 119 villages in T Narasipur Taluk (Mysore district) in the
1 A TaluKa is a sutx- region in a (fsirict
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state of Karnataka with a package of health, education and livelihood projects.
Thereafter, it entered into a partnership with the state government to manage a string
of PHCs (28 PHCs / PHUs and 138 sub-centres) covering 23 out of the 28 districts of
Karnataka. Thus, while most of the integrated activities are now centreed on villages
in Yelandur Taluk (Chamrajnagar District) and T Narasipur Taluk (Mysore district),
the Trust now has a state wide presence, through its PHC management programme.
It has also initiated similar work in 9 districts of the state of Arunachal Pradesh in the
north eastern part of the country, covering 9 PHCs and 36 sub-centres. In terms of
interventions, subsequently, the Trust has expanded its sphere of operations to
include, education, livelihood and community development, besides a range of health
care activities, including epilepsy, mental health and dental care, amongst others.
Public-Private Partnership initiatives and development of innovative and replicable
health care models is the key approach being adopted. Thus, begun as a response
to a single disease, and initially as an independent programme, the Trust has now
grown to become a full fledged organization with a vision and mandate of its own,
working in close collaboration with the state at several levels, although ideologically
following the same philosophy as VGKK.2
2.2.2 Vision and purpose
VGKK, and subsequently the Trust, appears to owe its origin to the personal
experience of its founder at a very young and impressionable age, when he lost a
parent due to the lack of adequate medical facility in the village. This, coupled with
his exposure to the teachings of Swami Vivekananda, a Hindu philosopher of the
19th century, led him to opt for working with the poor after he obtained formal training
in medicine. Although not a Faith Based Organisation in the true sense of the word,
the basic philosophy of Swami Vivekananda of an equitable society and service to
mankind permeates the vision and mission of the Trust This philosophy has also led
to the founder’s involvement in other rights based activities like the Rejuvenate India
Movement, of which he is currently the President.
Self reliance of marginalised communities: It is obvious that VGKK and the Trust
operate as separate orga zations with separate mandates, with the principal
difference being that while the former supports the tribals in the region, the later
provides health care services to the non tribals. While VGKK has a vision for a
‘...self-reliant, united and progressive Soliga tribal community’ (Das Gupta and
Ghanshyam, 2006), the Trust specifically focuses on health, and to some extent, on
education of both the tribal as well as the non- tribals in the rural and urban areas
with empowerment as an overarching issue. A subtle difference between the two
organisations perhaps is explained by one of the senior staff of the Trust as ‘VGKK is
surreal while the Trust is professional and replicable’. This definition indicates the
greater influence of specific philosophical ideologies of equality and service on the
former and the programme oriented approach of the later primarily aiming to improve
existing systems. Then again while VGKK appears to be a way of life, the Trust
translates some of its princip’es into functional services.
The approach of the Trust to rural development is ‘...holistic, democratic,
decentralised and participatory../ and takes into account the ‘...cultural and regional
differences...’ while aiming to empower every individual. It therefore seeks to provide
the necessary information, knowledge and skills to lead a healthy life. Hence, the
2 VGKK has grown into an integraled dewtopment programme tor the tribals and focuses on the broad areas ot hearth, education,
community development, community organiz -.’ion, sustainable livelihood and conservation ot bio- diversity It has also expanded its
area of operation to other regions of Karnataka State (Ydandur and C^nrajanagara) as wen as other States like Tamrt Nadu,
Andaman and Nicobar and Arunachal Pradesh
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PHCs attempt to focus on ^..community-oriented preventive medicine, instead of a
top-down approach.’ (Rademachers et al, 2005)
Thus, while the vision statement of the Trust declares that the organisation aims for a
‘...society in which we strive to provide an equitable and integrated model of health
care, education and livelihoods by empowering marginalized people to become self
reliant,’ the mission in turn is to ‘...develop a dedicated service- minded team that
enables holistic development of marginalized people, through innovative replicable
models, with a passion for excellence’ (Karuna Trust leaflet). Equity, integrated
development around the issue of better health services and empowerment and self
reliance of the community are central to the mission. And interestingly, the director of
the Trust states that ‘...It is not enough to create excellence, creating impact is
necessary...My basic agenda is to provide quality health care to the people of
Karnataka...’ (Vijay 2003) The Trust has consciously opted to work among the
marginalised tribal and backward communities, who are both socially and
economically backward. Largely located in remote and inaccessible areas these
communities are also often deprived of development resources. This backwardness
has also compelled the Trust to work very closely with the communities through
community based groups. The focus is on empowering the communities to prevent
diseases and promote good health rather than only provide curative medicines.
Good governance is central to effective service delivery: The Trust does not
intend to work like a ‘contractor*. According to Sudarshan, ‘contractors’ in the Indian
system are synonymous with corruption. He concluded that for the Trust, partnership
is ‘...an integration of ideas and activities...’ and that it ‘...works on the basis of a
humanistic philosophy.’ Within such a philosophy there is no place for corruption and
the issue of corruption has received considerable attention from the Trust in general
and the director in particular. ‘Good governance is one of the most important factors
in improving the health services. Merely adding new technological packages are not
enough and they may improve the out come marginally.’ (Director, Trust) While the
Trust attempts to make the functioning of the PHCs as transparent and accountable
as possible, by involving community institutions, the director, himself has been
crusading against corruption in the health sector since several years. He has also
been the Vigilance Director in the Karnataka Lok Ayukt, the principal corruption
fighting body in the state, and is widely recognised as a professional out to clean the
system. This is reflected in the value system of the Trust which does not accept any
bribe and orients every staff to this philosophy of the organization. An example of this
commitment to transparency and accountability was the removal of a medical officer
from a Trust- managed PHC on charges of corruption. The post remained vacant for
a long time affecting the work, but the Trust convinced the community that a vacant
post was better than a doctor who was corrupt.
The influence of the overall service and ‘humanistic’ philosophy is somewhat
reflected in the overall functioning of the organization in terms of the dedication of the
staff, the low cost and functional infrastructure and also the long tenure of some of
the staff members. Within this framework, the Trust defines its core objectives as
(Karuna Trust, 2006):
• Provide integrated development of the focus group - tribal and urban and
rural poor - through health, education and training for livelihood;
• Empower and organise the rural poor to become self reliant;
• Enter into public-private partnership for innovative, replicable and sustainable
model of integrated development of the marginalised community;
• Integrate mental health with primary health care and establish facilities for
care and rehabilitation for both men and women;
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•
•
•
Support the government to improve the quality of education through improved
teaching, resource material and community participation;
Promote vocational training and develop profitable business models for
manufacturing and distribution of in- house products; and
Advocate in order to influence government policy and reforms and to enable
other NGOs to adopt models in their respective areas.
2.1.3 Activities
The Trust, in order to realize its objectives has over the years initiated activities that
can be grouped into Health Care, Education, Livelihood and Community
Development, although health remains as the core function:
a. Health
Integrated services in Gumballi and T Narsipura: The first project of the Trust was
its own funded leprosy programme in Yellandur in 1986, which was subsequently
supported by the state on a district wide scale under its Leprosy Control Programme.
Subsequently, Epilepsy (1990), Tuberculosis (1992) and mental illness (1995)
gradually became part of its service portfolio. In fact, the Trust claims to have
introduced the method of administering drugs to TB patients under the supervision of
para medical workers, long before WHO launched its DOT programme in the country.
Mental health included setting up help lines, providing transit care and rehabilitation.
By the turn of the century, comprehensive eye care, community dental health a
mobile dental units, cancer detection, promotion of safe drinking water and sanitation
had been added to the list of services. Each service was bom out of a felt need and
as way of addressing existing service delivery gaps. Significantly, it was also built
around the existing national health care progammes. The services were not limited to
curative care but also included prevention through awareness generation and health
education. Research, setting up of testing facilities, provision of required drugs as
well as establishing a cadre of trained para professionals was part of the strategy.
Thus, over the years the Trust not only diversified into other health care services but
evolved a holistic health care programme and reports that it has progressed from
curative health through community health and community development to
sustainable development (Annual Report, 2006-07).
‘We look at health in a holistic manner, rather than as one that needs
isolated curative services. We have attempted to address either directly,
or indirectly, every health need that people have. Indirect needs could
mean safe drinking water, or sanitation, which ultimately lead to better
health among the people.* (Sudarshan, quoted in Das Gupta and
Ghanshyam, 2006)
In both these project areas the Trust also began to address non- health related
issues like livelihood, micro-finance and primary education, which obviously had an
effect on health and the overall quality of life. Thus, the range of activities in these
two project areas includes:
• Primary Health Care - PHC at Gumballi
• National Health Programs - Leprosy, Tuberculosis, Mental Health & Epilepsy,
Chronic/Non-communicable Diseases (Diabetes, Hypertension & Cancer)
• Comprehensive Eye Care — Vivekananda Eye Hospital and community-based
eye care (Yellandur)
• Mobile Dental and health unit
• Rural Livelihoods - Vocational training programs at Gumballi, Food
Processing Unit & Herbal Medicine Processing
• Community Micro-finance and Health Insurance
• Integrated Education Program
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•
•
Referral Support - Ambulance (T. Narsipura)
Diet service in District Hospital (T. Narsipura)
Sanitation program (T. Narsipura)
Village Resource Centre (T. Narsipura)
Public-private partnership in the management of PHCs:
While the health services evolved as separately funded programmes and were
initially delivered through the Trust’s integrated projects in Yalandur and Narasipur
and catering to a cluster of villages in the area, they subsequently also became an
integral part of the services provided by the PHCs under the management of the
Trust. Since then 25 PHCs and PHUs have been handed over to the Trust across the
state. The PHCs have apparently evolved into innovative models of public- private
partnership.
In 1996 the state Government of Karnataka handed over the PHC at Gumballi,
together with 5 sub-centres under it (covering Yelandur Taluk and the tribal
population living in the hamlets scattered across BR Hills) to the Trust as an
experiment in public- private partnership. This model has been adopted under the
Tenth Five Year Plan and currently the Trust while running 25 PHC across 22
districts in Karnataka is also managing 9 PHC in the State of Arunachal Pradesh and
supporting other state governments to launch similar experiments.
Over the years the innovations have been packaged into well defined components
that include:
• Mainstreaming of HIV-AIDS in primary health care services
• Epilepsy control programme
• Integration of mental health care
• Mainstreaming traditional medicines in primary health care
• Community Health Insurance
Other unique features of the PHCs are:
• Community participation through village health committees
• 24 hour service with the staff living on the premises of the PHC.
• Gender sensitive care
• Development of an improved system of management of the PHC including, a
Health Monitoring and Information System (HMIS) and generation of gender
disaggregated data.
Other health related activities:
Community Health Insurance: The Trust implemented a community health insurance
programme in Karnataka between 2002 and 2005. The project was undertaken on a
pilot basis in partnership with UNDP, National Insurance Corporation and the
Government of India. Implemented in phases it eventually covered 332 villages in
Naraipura taluk (Mysore) and Bailhongal taluk (Belgaum) in the first phase and 173
villages of Yallandur Taluk (Chamrajnagar) and Belgaum taluk (Balguam) and 57
tribal hamlets of BR Hills (Chamrajnagar). A community based model of health
insurance evolved with the following features: low premium, no disease exclusion,
immediate settlement of claims, provision for security against wage loss and out- ofpocket expenses, and cover for surgery and drugs. The project was funded by UNDP
and came to an end in 2005. The State government apparently intends to scale it up
and the Trust plans to introduce a pilot project together with UNDP and National
Insurance Corporation, for antiretroviral drugs for people who are HIV positive.
Mansa and community health programme: The ‘Mansa’ project focuses on health
and care of the mentally ill through the Community Mental Health component
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integrated into the services of the PHCs managed by the Trust, a Home for treatment
and care of destitute mentally ill women in Mysore, and the psychiatric services at
Nirashrithara Parihara Kendra (Beggars’ Home) in Mysore, run by the State Social
Welfare Department.
Tele medicine The Trust has in recent years (2005) introduced telemedicine services,
initially under a pilot project called the Integrated Tele-cardiology and Telemedicine
Project, in collaboration with a renowned private super-specialty heart hospital(
Narayana Hrudayalaya, Bangalore). The tele- conferencing itself is facilitated by the
Indian Space Research Organisation, Department of Space, Gol, (ISRO) as part of
its space application technology activities, under which ISRO has provided facilities
for the Trust to set up Village Resource Centres to focus on education, agriculture,
health and watershed. The Trust is now using the facility to monitor the PHCs
through tele- conferencing and to implement the tele- medicine programme in the
PHCs at Chamrajnagar and MM Hills.
Shivasamudra and Shimshapura Hospitals: In 2001 the Trust took over the
management of the two clinics at Sivanasamudram and Shimsapura under an
agreement with Visweswarayya Vidyut Nigam Limited (WNL). The clinics cater to
the employees of WNL and state government undertaking for the generation of
electricity, the villages nearby and the migrant labor working at new hydroelectric
projects being setup in the area. The Trust is attempting to provide similar services
as that provided at the PHCs through these clinics, apart from capacity building of
staff and overall improvements in management.
Promotion of low cost generic drug and Rational Drug use: For this purpose the Trust
has entered into a partnership with LOCOST, a Baroda based pharmaceutical
company for distribution of low- cost and quality essential drugs to NGOs and
hospitals.3 It also stocks Biocare Pharmacies for generic drugs in collaboration with
Arogya Raksha Yojana Trust.
Mobile Dental Units: The Trust has started a mobile dental care unit functioning
under the Gumballi PHC to provide dental care to remote villages in Yelandur, T. N.
Pura and Chamrajnagar blocks and covering a range of 800 Kms. The clinic provide
prophylactic care, restorative and corrective interventions as also follow up and
awareness regarding dental hygiene and care. The unit visits around 13 PHCs every
month.
Vivekanad Eye Hospitals: The Trust has set up the Vivekananda Eye Hospital at the
Gumballi PHC for ophthalmic care and functions as an independent unit in
coordination with the ANMs and health workers and under the guidance of a
renowned ophthalmologist from the Vittala International Institute of Ophthalmology,
Bangalore and his team. It provides both preventive and curative hospital based care
and follows up and covers 4 sub-regions of Chamrajnagar district and two in the
Mysore District.
Homeopath Clinic: The clinic, started about 3 years back, currently operates only on
the weekends and treatment and medicines are free except for a one time nominal
registration fee
ANM School: Niveditha Female Junior Health Assistant School was launched in BR
Hills in October 2006. Approved by the Government of Karnataka it caters to the
training of auxiliary nurses, most of whom belong to the tribal or socially backward
3 In the year 2006-06 the Trust reports a total sale of drugs worth Rs. 2.6 million under this programme.
12
communities. The first batch of 30 students is currently under training (18 months
course). For practical trainings the students are placed at the local district hospital.
Internship programme: The Trust has a unique arrangement with State level medical
colleges to provide internship facilities for students in the various PHCs. While, this
provides an opportunity for students to be exposed to rural community based health
care, it provides the Trust with much needed trained manpower.
Promotion of traditional medicines: The Trust is attempting to revive the use of
traditional medicines by documenting traditional knowledge and assessing and
validating the practices for effectiveness and replicablity. Effective practices are then
distributed through PHCs managed by the Trust and Government Ayurvedic
Dispensaries. An integral component is support for the propagation of herbal
medicine plants through SHGs and PHCs. The Trust has set up an Herbal Medicine
Processing Unit in BR Hills with a drug license for production of more than 40
traditional Ayurvedic drugs.
Hospital service at T Narsipur: The Trust also provides non- clinical services like
ambulance and free diet at the hospital in Narsipur, since the year 2000.
b. Integrated Education Project
An integrated project called Samagran Shikshan Project was initiated in 2003 in
partnership with the State Resource Centre, and US based India Literacy Project.
Initially launched in 40 villages of Yalandur taluk, in 2005 it was extended to
Narasipura, Kolar and Gowribidanur taluks. The project focuses on pre- school,
school and adult education and addresses the needs of three groups within the
community: 0-6 age group and 6-14 age group of children enrolled in anganwadis
and schools as well as those who are out of school in these age groups; and
illiterates in the productive age group of 15-35. The project seeks to completely
eliminate illiteracy, increase enrollment, decrease dropouts and develop an
integrated education cum literacy model. The inputs, true to the Trust aim to
empower communities and improve the quality of services, include:
• Strengthening of the Balvikas Samitis (Child Development Committees) at the
Anganwadi level;
• Building the capacities of the School Development Committees;
• Capacity building and monitoring of teachers for quality education;
• Establishing a cadre of village volunteers for adult education and mobilizing
dropouts to re-enter mainstream education; and
• Strengthening continuing education centres.
c. Livelihood and Community Development
The Trust believes that strengthening of livelihoods, community development and
empowerment are overarching conditions for sustaining any development
programmes. Therefore the Trust has initiated several activities in Yelandur and T
Narsipura Taluks. These include:
• Setting up of a network of women’s SHGs who are also involved in income
generating activities, community health insurance, herbal medicine
processing and community micro- finance ( primarily savings and credit
groups);
• Setting up Village Resource Centres in collaboration with the Indian Space
research Organisations to provide tele-education, tele-medicine and both
technical and market related information for agriculture;
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•
•
•
Collaboration with the GREEN Foundation to promote multi- cropping and
sustainable agriculture through use of traditional seed conservation and
organic farming targeting the small and marginal farers;
Initiating several vocational training and livelihood activities; and
Community development, including Community Convergent Action, formation
of Village Development Councils and convergence of services a village level
by leveraging existing government programmes.
Spiritual empowerment of the rural poor through self reliant and participatory
community work is being implemented on a pilot basis. Voluntary work for the
development of the village is a key approach.
This case study focuses on the management of PHCs under a public-private
partnership framework.
2.1.4 Organisational structure and management
The Trust is registered as a charitable trust under the Indian Trust Act of 1851 and
as such is eligible for tax exemption. It has also acquired clearance from the Home
Ministry for accessing external donor funds (FCRA). It is governed by a Board of
Directors, headed by a President of tribal origin and hailing from the area where the
Trust began its activities.
For administrative purposes the Trust is divided into six regional offices with the head
office located in BR Hills, Chamrajnagar and the administrative office at Bangalore,
the capital of the State of Karnataka. Besides, there are two separate offices at
Yelandur Taluk, Chamrajnagar and T. Narsipura for the integrated projects being run
here. There is also a Training Centre at Mysore located within the Technology
Resource Centre, which manages the Manasa Project at Mysore and coordinates the
training programs. Outside the State of Karnataka the Trust has regional offices at
Itanagar and Roing in Arunachal Pradesh and another one in Port Blair, Andaman
Islands. While the Bangalore office has an oversight of the PHC public- private
partnership programme in both Karnataka and Arunachal Pradesh and is also
responsible for all the PHC related innovations, stocking and distributing the drugs
and advocacy, the Port Blair initiatives, launched 4 years back, have now been
brought together under a separate unit of the Trust registered in the Andamans.
The Bangalore office functions out of a small but well equipped and functional
building which has been recently constructed on land donated by the State (in
recognition of the services rendered by the director) and through donations from
individual donors. The core team located in Bangalore consists of the Director( Dr.
Sudarshan), a Project Director, a Project Co-ordinator, two Field Co-ordinators each
responsible for a group of PHCs, an Office Manager, Accountant, Pharmacist and an
Office Assistant While the day to day activities of the PHCs in Arunachal Pradesh
are taken care of by a Co-ordinator located in the State, close support is provided by
the Project Director and Coordinator from Bangalore, both of whom are also doctors
by training and experience. The two Field Coordinators are each responsible for the
two integrated projects at Yelandur and Narsipur. Each PHC has a team of Doctors,
nursing staff, technicians and management and administrative staff.
14
Fig 1:Karuna Trust - Structure for PHC Management
Board of Trustees
I
Director
J
r
Regional
Offices (6)
I
Karnataka Project
Port Blair Project
I
Administrative
Office (Bangalore)
Arunachal Project
Integrated Project
Office (2)
I
Training Centre
(Mysore)
PHC Management
Project Director
Project Coordinator
r
Field
Coordinator (2)
I
Off. Manager
I
Accountant
4
Pharmacist
I
Off. Assistant
l
PHC (28)
The leadership of the Trust is an ‘inspired’ one: inspired by the founders philosophy
of equity and enhanced quality of life for the poor and marginalized, much of which is
more evident in the manner in which the integrated projects at Yelandur and T
Narsipura have evolved and the various attempts to provide quality services at the
lowest of costs. A process of collective management and voluntarism is visible in the
way that the flagship project at BR Hills (Yallendur) is managed, albeit under the
banner of VGKK. While, much of the responsibility for operational management of the
Trust itself has been devolved down to the Programme Director and his team as also
the running of the Training and Resource Centre at Mysore, it is clear that the Chief
Functionary has a large role to play in terms of vision and directional goals. While the
chief functionary allocates a substantial amount of his time for his larger roles at the
State and national level, he remains connected to the ground activities through the
project in the BR Hills, where he tends to spend a considerable amount of time and
takes weekly meetings. This is perhaps in a way a weekly spiritual pilgrimage to the
15
place and people that inspired him to initiate work.4 However, as the programme has
spread over the years, his visits to the other project areas have considerably reduced
and are limited to events of critical importance.
It was interesting to note that while programme and financial records are meticulously
maintained, decisions ranging from activities to be undertaken to positioning of staff
are taken with quickly and verbally communicated, to ensure that activities flow
without much interruptions. While regular weekly meetings are held between the core
team in Bangalore and the chief functionary, updates and monitoring of activities are
earned out through exhaustive site visits and increasingly also through tele
conferencing. However, it was also observed that while the staffs at the PHCs
interact to some extent with the District and Taluka Health Offices, the senior
mangers visits are limited.
Although the individuals of the core team have clocked anything between 3 to 8
years with the Trust, difficulties are being encountered in sustaining the staff in the
PHCs for longer durations. It is also obvious that for a large number of the medical
professionals in the team, the Trust is a learning centre and gives them valuable
experience in community based health delivery services and an opportunity to
sharpen their skills. In fact, the credibility of the Trust has led it to be seen as a
stepping stone to better employment. Thus, while many of the staff is motivated to
continue with the Trust because of the nature of work, others remain till they find
alternative and better paying employment in the government or private sector. For
money others, it is an alternative employment after retirement and closer to their
roots or place of origin.
Recruitment across the board is often made on informal basis, with potential
candidates often approaching the Trust for long term or temporary work or internship
and being quickly absorbed into the organisation. Decisions to employ are also taken
by the Programme Coordinator. The senior staff indicated that quick turnovers and a
constant shortage of staff in the PHCs forced them to recruit either professionals with
little experience or often those who had retired from government services and were
looking for alternative employment.
Over the last three years, out of a total of over Rs. 65 million received as grants and
donations from various sources, the largest contribution accounting for 57
percentage of the total funds has been received from the state ( Gol, GoK and its
various departments), while donations from individuals and private institutions
accounted for 15 percent and other institutional grants (UNNDP, FPI, Helpage India)
and user fees together accounted for the remaining 28 percent. Apart from PFI and
UNDP the Trust does not have any other large institutional funders. The Trust
manages to generate funds from individual donors, most of who are natives of the
state of Karnataka but now settled out of the country and are keen on contributing
towards its development. The Trust effectively plays on their ‘guilt feelings’. Most of
these funds are used to develop additional and upgraded facilities for the various
PHCs under its management as also the integrated project in BR Hills where the
NGO also runs residential boarding schools for the tribal children.
4 This zeal and comtralment has won him the Right Uvelihood Award in 1994 for contributing towards preserving tribal culture and
showing how this could be addressed in such a way that it helps indigenous tribes to secire their basic rights and fundamental needs.
16
2.2 Department of Health and Family Welfare
2.2.1. Health care and systems in Karnataka: the context
Karnataka is one of the fastest growing states in India in terms of per capita income
and is also rated as being above the national average in terms of the overall health
status and the health care delivery system. Apparently a wide network of primary,
secondary and tertiary institutions have been established in the state providing
comprehensive health care services while state policies have led to the
establishment of medical, nursing and professional health education institutions
ensuring reasonably good supply of health professionals. In fact, the overall health
status of the population has also shown improvement in terms of higher life
expectancy, decline in birth and death rates and substantial control over infectious
disease Moreover, over the last few years the state government has also developed
policies and undertaken initiatives that have led to improved infrastructure as well as
dialogues and participation with the voluntary organisations (Government of
Karnataka, 2001; Government of Karnataka, 2005).
However, there are regional differences as well as disparities amongst different
socio- economic groups, which have apparently widened over the decade and
effectiveness, access and inclusion of the most vulnerable communities have been of
concern. Neglect of public health and distortions in primary health care in the State in
recent years, as also have other issues like a lack of focus on equity, gaps in
implementation, cultural gap and medical pluralism, corruption, a decline in the
ethical values and growing apathy in the system have been attracting increasing
criticism. In fact poor institutional capacities, inadequate attention to essential
services, inadequate health financing strategies and widespread growth of the private
sector without a balancing mechanism to upgrade standards and ensure quality and
cost of services have been found to be other gaps in the system. Besides, while it is
believed that the political economy of health has been always neglected, poor status
of human resource in the health sector and the exclusivity of the government for
health service provisions at the cost of ignoring the potentials of the community,
private sector and the civil society organisations have not helped in improving the
sector (Government of Karnataka, 2001).
‘The relatively low level of public confidence in public sector health
services, particularly at primary health centres, is recognized. Lack of
credibility of services adversely affects the functioning of all programmes.
Underlying reasons for implementation gaps need to be understood and
addressed.’ (GoK, 2004)
This has led the state to take various corrective policy measures and effect
institutional changes in recent years, the most important being the development of
the State Integrated Health Policy.
2.2.2. Public action
Purpose and agenda
The Karnataka State Integrated Health Policy of 2004 clearly defines the present
vision and mission of the health sector based on beliefs and values of
comprehensive and integrated services. The state has adopted the principles
developed by WHO in 1978, which defines health as " ‘a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity’,
creating the ability to lead a ‘socially and economically productive life’ (GoK, 2004).
Comprehensive and integrated care is thus the basis of the state’s primary health
service policy and its’ mission is to provide ‘improved access to good quality health
care and promote an enabling environment for development of the health sector.’
17
Equity, responsiveness to the needs of the people, and ‘...transparency,
accountability and community participation’ are some of the key principles it aims to
follow. This implies health care service with a focus on promotive, preventive,
curative and rehabilitative care at the primary, secondary and tertiary levels and an
effective link to a good referral system (GoK, 2004) Accordingly, the State has
adopted the following goals and the provision of:
• An integrated and comprehensive primary health care.
• A credible and sustainable referral system.
• Equitable delivery system.
• Public private partnership in provision of quality health care in order to better
serve the underserved areas.
• Improved health infrastructure.
• Enhanced human resources.
• Safe and quality drugs at affordable prices.
• Systems of alternative medicine.
Further, the State recognizes the value of both public health and primary health care
and attempts to bring about a synergy between the two through inter-sectoral
coordination, community participation and equitable distribution of services. It also
gives due recognition to the socio- cultural, demographic and economic diversities of
the State. Moreover, it recognizes the critical role played by the private sector,
including the NGOs in health care delivery and is committed ‘... to play a facilitating
role in harnessing resources, energies and ideas from private and voluntary sector.’
(GoK, 2004)
Activities
Within this policy framework the Department of Health and Family Welfare provides
public health services and comprehensive health care which includes promotive,
preventive and curative care cutting across cutting across various health issues. The
services are largely provided through national and State funded programmes
including the rural health component of the erstwhile Minimum Needs Programme,
Medical Development Programme and Hospital Pharmacy Programme, a number of
vertical national programmes like Reproductive and Child Health (RCH), TB,
Blindness Control, Malaria, AIDS control, etc., Prevention and Control of
Communicable Diseases, Nutrition Education and Demonstration Programme, Health
Education and Training, Laboratory Services and Vaccine Production Unit, Education
and Environmental Sanitation and Curative Services, etc.
Some of these
programmes have been in existence since over a decade and have gone through
several phases of implementation. For instance RCH is being implemented from
1997 as a 100% Centrally Sponsored Scheme, with the objective of not only
stabilization of the population but also to improve the health of the mother and child
and has now entered into a second phase; TB has metamorphised from routine
control and clinical treatment to DOT or Direct Observation Therapy method;
similarly, a School Health Service is being implemented since the early 1990s and
includes comprehensive care of health and well being of children throughout the
academic year. HIV-AIDS is of relatively more recent origin but has grown in
importance to merit a separate institutional set up within the sector and a large
amount of dedicated funds focusing on awareness and education, counselling and
care.
Since the early 1970s, the state has also been implementing several externally
supported programmes focusing largely on strengthening primary health care
services, and to some extent also the secondary services in the state (although in
terms of budget, secondary and tertiary have a larger share, perhaps because of
18
their infrastructure focus). While some of the primary health care projects are
comprehensive in design (IPP IX and UNICEF) others have a vertical focus on single
diseases like AIDS, TB, etc. The externally ftinded projects include the Word Bank
funded IPPVIII and IX (India Population Project), KfW funded focusing on improved
services at district and sub-district levels, UNICEF supported projects, etc. A major
programme of the Department since 1996 has been the implementation of the
Karnataka Health Systems Development and Reforms Project, funded by the World
Bank. The Project is currently in the second phase of implementation. While the first
phase focused on the revitalisation of 200 secondary level hospitals the second and
current phase has a wider remit. It aims at improving delivery of services in the
secondary hospitals, through increased utilization of essential curative and public
health services of adequate quality, particularly in underserved areas and among
vulnerable groups. The essential services include all those services that can improve
maternal and child health outcomes and reduce communicable diseases. While
some of these are implemented as state components of the Government of India
supported programmes, others are state level projects (Narayan, 2001).
Besides, the Department runs district hospitals which provide a range of specialist
services from medicine, surgery and pathology to obstetrics, gynaecology,
orthopaedic, ENT, ophthalmology and psychiatry; it manages several public health
institutes, like diagnostic labs, water testing labs, food testing labs, etc.; and also
runs medical educational institutions for ensuring continuous availability of trained
professionals and para-professionals.
2.2.3 Organisational structure and management
The DH&FW delivers these services through an elaborate health structure and a
range of medical institutions. In fact the health care delivery system in the state has
been developed based on the guidelines issued by the Government of India and the
recommendations of various national committees like the Shore Committee, the
Mudaliar Committee, etc.
The state thus set up a specific delivery system and created the Department of
H&FW under the Minister of H&FW. A Directorate for Health and Family Welfare
(DH&FW) was subsequently set up to take care of all the health related services,
apart from the establishment of separate Directorates to oversee the activities under
the Medical Education and Indian System of Medicines and Homeopathy
components, together with a Drugs Control Department, all under the Department of
Health and Family Welfare. This case study primarily refers to the Directorate of
Health and Family Welfare responsible for the primary health care system and
structure.
The rural health service is provided through a three tier structure that includes, sub
centres at the lowest level, PHCs at the next level and Community Health Centres at
the highest level. This three tier network is the standard format across the country for
health care delivery in the rural areas and it is through this structure that all the
national programmes and the comprehensive health care services are delivered. In
fact, the PHCs with its backward and forward linkages perform two sets of activities:
the first is the preventive and promotional functions under which the national
programmes are implemented and monitored; and the second the curative functions.
At the lowest level and closest to the community is the Sub Centre. One Sub Centre
with a female health worker is established for every 5000 population in plain areas
and for every 3000 population in hilly and tribal areas. It is the closest point between
Primary health Care System and the Community. Currently there are over 8140 Sub-
19
Centres in the state. At the next level is the PHC, wherein one unit caters to a
population of 30,000 in the plain areas and to 20,000 in the hilly and tribal areas.
Figure 2: Organisational Structure of Directorate of Health and Family Welfare,
Karnataka
Commtssioner
H&FWS
4^
Director
SIHFW
Director
H&FWS
¥7.
PD
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i
AD
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(RCH)
|" CAO |
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DO
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DO
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JD
JD
DD
-4
y ~
___II DD II DD |
DO
1
DD
Mr
♦
CAO (FW) I
4^
JPD RCH I
1
DO
i.
DD
DDP
I
JD(IEC)
~T~
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CTO
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Demographer
I
DD
(PPP)
—T
jL
DD
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jr
SrPjpr
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| Computer |
Source: Adapted from the website of DH&FW to show the elaborate network of Additional
Directors(AD), Joint Directors(JD), Project Directors(PD) and Deputy Directors for programme
management and Chief Accounts Officers(CAO) for administration.
The PHC is the first contact point between the rural community and the Medical
Officers and consists of a team (technically 14 in number) of paraprofessionals and
other staff headed by the medical officer. It is also the referral unit for 6 Sub- Centres
and has facilities to take care of a small number of in-patients. The PHC provides the
entire range of activities from curative to preventive, promotory as well as family
welfare services. There are 2195 PHCs and 17 urban centres in the state. At the third
and the highest level is the Community Health Centre, established for a rural
population of 100, 000. The CHCs consist of a team of specialists including a
Surgeon, Physician, Gynaecologist and Pediatrician supported by paramedical and
other staff. It has facilities for in- door patients OT, X-ray, Labour room and
Laboratories. There are 249 Community Health Centres in the State (GoK website).
In order to manage this three tier system the DH&FW has established a District
Health Office headed by a District Health Officer (DHO) in each of the 28 districts
District and a Taluka Health Office, headed by a Taluka Health Officer (THO) in each
of the 175 Talukas. While the THO provides is responsible for support and day to day
monitoring of the PHCs and the sub- centres attached to it, the DHO provides the
20
oversight. The DHO also has a team of specialists who manage the various
programmes.
The state has a budget of over Rs.1243 crores (124.3 million) in the current year
(2007-08) for RCH and public health programmes, a tremendous raise from Rs. 377
crores (37 million) in 2004-05. This includes funds from the centre as well as the
state. In terms of external funds while UNICEF and DANIDA have initially been major
supporters and while the former still continues to be a key player, currently the
largest source of external funding is the World Bank. Besides over the years there
has also been an apparent shift from a grant to a loan component.
2.3 Positioning of the Trust and DH&FW within the sector
While both the Trust and the DH&FW are committed to equity in delivery of health
services as well as have seemingly adopted a comprehensive service delivery
package there is obviously some difference in the way the organisations are not only
structured but also in the definition of the value systems and its practice. The Trust
has grown out of the specific needs of the community, specially the tribals that it
serves. Hence, it attempts to tailor its services accordingly.
In terms of its organisational structure, although it is now spread across the state and
has several categories of employees the decision making is simple and quick unlike
the hierarchal structure of DH&FW. It also has the additional advantage to innovate
and raise its own funds for the purpose, all of which makes for a more efficient
system of service delivery.
3. CONDITIONING FACTORS
A number of factors have influenced the agenda and the structure of both the
DH&FW and the Trust. While the DH&FW has been largely governed by Central and
state programmes and policies, the Trust has been effected by these same policies
as well as its own ideological commitments to preserving the traditions and cultures
of the community. It has also been influenced by the global approach to holistic and
comprehensive primary health care. The fact that the director of the Trust has held
key positions in several policy forming committees at both the state and National
level is significant and has admittedly influenced the policies of the state and perhaps
to some extent even at the national level.
3.1 Policies of the Central Government shape programmes and structure
Health care, as mandated by the Indian Constitution, is a state subject, implying that
all decisions regarding the structure and services to be delivered as well as their
management are the responsibility of the respective state governments. However,
the Central government plays a critical role by holding the States to account in terms
of national and international commitments to improve the health status and also by
channelling some critical targeted resources, although the health expenditure is
largely met by the state, with 82% (public sector expenditure) being accounted for by
the Government of Karnataka and 18% from the Central Government. This is
perhaps what allows the state to have a steer on the quality of services and evolve its
own policies to some extent.
In Karnataka, like in other states the health care system and services have been
based on guidelines enshrined within successive national Five Year Plans, decisions
of the Central Council of Health and Family Welfare, central health legislation and
21
national health programmes, including the Central Government’s goal of Health For
all by 2000 in line with the National Health Policy. Thus, while over a period of time
separate policies at the National level have been developed for Health (1983 revised
in 2002), Nutrition (1993), Drug Policy (1986 revised in 1994), Pharmaceutical Policy
(2002) and Medical Council of India (MCI) guidelines (1998,1999 and 2000),
Karnataka has attempted to translate these into state level goals and operational
plans. The vertical national programmes currently being implemented in Karnataka
are the result of these policies and guidelines.
Commensurate with these programmes, over the years the Central Government set
up several Commissions to recommend a suitable structure for the delivery of
primary health care services, and the three tier structure of primary health care
followed across the country, including Karnataka, is an outcome of these
recommendations (Shore Committee, Mudaliar Committee).
The National Rural Health Mission, lunched across the country in 2005 is the most
recent in the line of central policies. Although Karnataka, because of its rating as one
of the better performers in health, is not listed amongst the 18 focus states, still
comes under the scope of the Mission. As such it needs to comply with the vision of
greatly improving the health system and promote policies that would strengthen
public health management and health care delivery in the state. Some of the key
components of the Mission are the provision of a female health activist or ASHA, in
each village; a village health plan prepared under the supervision of a Village Health
and Sanitation Committee (Panchayat); strengthening the delivery of primary
healthcare; revitalizing the local health traditions and mainstreaming AYUSH into the
public health system; effective integration of health concerns with determinants of
health like hygiene, sanitation, safe drinking water and nutrition; decentralisation of
programmes for district management of health; and improving access, especially of
marginalized rural communities, including women and children, to ‘equitable,
affordable, accountable and effective primary healthcare/ In order to realize the
mission, NRHM has outlined specific core and supplementary strategies which
encompass a range of activities and interventions from capacity building to improved
structures and facilities, all of which are slated to be achieved by the year 2012.
The other significant move on the part of the Central government, reflecting its
serious intent to facilitate a partnership approach was the setting up of a high level
Task Force at the national level to recommend strategies for public- private
partnership in the forthcoming Eleventh Plan. The Task Force was to identify
potential areas in the health care delivery system where an ‘effective viable, outcome
oriented public private partnership’ was possible and to suggest ‘practical and cost
effective system’ of public private partnership. (Planning Commission,) It is significant
that the director of the Trust was member of this Task Force.
The draft Task Force report defines some of the objectives of PPP as improving the
‘quality, accessibility, availability, acceptability and efficiency, of health care through
exchange of skills and expertise, mobilization of additional resources, improving
management, expanding the range of services as well as the number of services
providers. It emphasizes the need to define the sharing of risks as well as community
ownership. The (Draft) Report identifies the following as potential areas for PPP:
• Services, disease control and surveillance, diagnostics and medicines.
- Infrastructure
Health manpower
Behaviour change communication
Capacity building including training and systems development.
Managerial service and auxiliary activities of the health sector
22
The report however cautions against expanding into too many areas in the initial
phase of PPP and recommends that the government funding should not exceed 15
percent of the budget allocation. It suggests a framework where (a) value for money
and (b) clearly defined sharing of risks are the base. It recommends that the
framework should also provide for costing of services and decentralization should be
the approach for management, while a network of resource centres at various levels
should provide technical and management support and ensure transparency.
Generic models of PPP should be adapted keeping in mind the regional variations.
The report concludes by providing certain principles for PPP but clearly cautioning
that PPP cannot be a substitute to ‘...resolve the dilemma of inadequate health care
for the people.’
However, Karnataka, much before the National Rural Health Mission was launched,
had initiated steps to correct existing anomalies and gaps in its health care services,
primarily relating to regional as well as urban and rural inequalities, poor nutritional
status of U-5 children and anaemia amongst women. Besides, the state was also
concerned about the overall poor health care status of women, relative neglect of
mental health and disability care. The outcome was the setting up of a state level
Task Force to look into these Issues and not only recommend solutions but also
monitor the implementation of the recommendations. One of the critical
recommendations was also the development of a comprehensive health policy for the
state.
In the case of the Trust, the concept of managing a PHC, launched with the Gumballi
PHC was in itself derived from the opportunities offered by IPP IX. Gumballi was a
difficult and backward area and had no health services and whereas IPP IX (India
Population Project funded by the World Bank) had the autonomy to initiate innovative
projects. Therefore, the Trust negotiated with the state and got two projects, including
Gumballi, approved on an experimental basis under IPP IX. Subsequently, the
states decision to expand the experiment led the Trust to expand its own scope of
work.
3.2 Task Force on Health and Family Welfare and Integrated Health Policy
A Task Force on Health and Family Welfare was hence constituted by the
Government of Karnataka in 1999 to specifically look into bringing about
improvements in the public health system in the state, propose ways of stabilizing the
population and recommend improvements in management and administration of the
DH&FW. The Task Force was also to recommend changes in the health education
system, including clinical and public health. An added remit was to monitor the
impact of the recommendations especially in the initial days. In the course of its
activities, the Task Force also recognised the need to address another critical issuethat of widespread corruption in the health sector and the lack of integrity. What is
significant to this study is that the Task Force was chaired by the director of the
Trust.
The Task Force made a series of short and long term recommendations focusing on
reforming the DH&FW and to improve the equity and quality of service delivery.
While addressing a range of issues from primary, tertiary and secondary health care
to multi-sectoral and inter-sectoral coordination, partnerships and decentralization, it
empahsised that state policies related to health were to be governed by the
‘...principle of equitable access to effective care to meet the needs of the people’,
and that minimum ‘acceptable standards’ need to be developed for health care
institutions, with the concept of ‘comprehensive primary health care’ being
propagated and accepted by both the people and the service delivery mechanism.
23
Therefore, PHCs need to be upgraded in terms of better infrastructure and adequate
manpower and a synergy should be brought about between primary health care
public health, including water and sanitation, solid waste management, hazardous
and bio- medical waste. Besides, a Health Monitoring Information System for
infrastructure, human resource and disease surveillance needs to be established for
overall management.
The Task Force also proposed, and in fact went ahead and developed, an integrated
health policy which was adopted by the state in early 2004. The policy is
comprehensive and includes sub- policies on health, population, drugs, nutrition,
control of nutritional anemia, blood banking, education for health sciences,
pharmaceutical, ISM&H and policy for communicable and infectious diseases. The
role of voluntary and private sector in improving health care is specially emphasized:
‘Participation of voluntary and private sector will be enhanced through outsourcing
certain services, in infrastructure maintenance and investments in health services.’
(GoK, 2004). The policy also recognizes the need to involve the community and to
institutionalise this process through the PRIs.
3.3 Externally aided programmes
The state health sector has also been influenced by the large number of externally
aided projects that have been present in the state since the early 1970s. These have
included international agencies like the World Bank and UNICEF and bilateral
agencies like DANIDA and KfW. Each of the external funded projects have had their
own focus and have included support to control of specific diseases like TB, HIVAIDS and blindness control, while others have been more compressive and
supported the wider issue of RCH (Reproductive and Child Health ) and population
stabilization and primary health care. Some of them were state components of Gol
projects while others were state specific projects.
A study undertaken in 2001 (Narayan, Ravi 2001) indicates that the World Bank has
been the biggest donor and over the years has become one of the only donor. And
not surprisingly therefore there has been a gradual shift from grant component to
loans over the years. The study adds that most of these projects, till the early part of
this decade have been stand alone projects and hence whatever synergies were
affected was unintentional, although this gave the project a certain amount of
autonomy to innovate. The Study is critical about the lack of capacity and ownership
of the DH&FW in most cases as also the effect of omnipresent corruption and the
lack of transparency and accountability in these projects like in the case of the
others. It also interestingly pointed out that a perception that most of these projects
were donor driven was because the state officials themselves tended to accept the
conditions and strategies, without contributing their own ideas.
3.4 Influence of the tribal culture on the Trust
The founders of the Trust had begun their work with tribals communities located in
scattered remote forest areas and not only have the Soliga tribes remained a core
focus of their activity, but the existence of VGKK, the parent organisation of the Trust,
is closely linked to the tribals themselves. This ideological relationship with the tribals
ensured that the founders of the VGKK and the Trust protected their ‘inherent culture’
and developed all interventions around it. This was because director and his team
believed that the tribals are an integral part of the forest and as such their future
depended on ensuring that they did not get alienated from nature. This led VGKK to
integrated traditional health practices and cures with modem medicines and also
subsequently led them to promote traditional medicines through the activities of the
24
Trust More importantly it was this need to preserve the traditional culture and ethos
of the Soliga tribes that let the director to create a separate unit to take care of the
health needs of the non-tribals.
4. SHAPING OF THE REALTIONSHIP
4.1 Growth of the relationship between the Trust and DH&FW
4.1.1 A beginning is made with the Leprosy Control Programme
As mentioned earlier, the Trust was launched with an independent leprosy control
programme targeting the tribals and non- tribals in Yellandur Taluka of Chamrajnagar
district. Within a year of its existence the Trust had brought the problem of leprosy in
the area under control and the Karnataka government, impressed with the early
results, entrusted the responsibility of implementing its Leprosy Control Programme
in the entire district to the Trust. Thus, the first formal collaboration between the NGO
and the state came into being in 1987 soon after the establishment of the
organization. The results have been impressive and the incidence of the diseases is
reported to have reduced drastically from a little over 21 percent in 1987 to less than
1 percent in 2002.
For the control and treatment of Leprosy the Trust adopted, what was known as the
SET method of treatment which involved elements of detection, education and
treatment and required a close interaction with the community as well as effected
households. During the process, the NGO discovered the presence of other diseases
like Epilepsy, various types of mental illness and TB in the community and gradually
began to take steps to control and treat these ailments too. As part of the
interventions it also interacted with the local PHCs and supported the doctors and
health workers through trainings and development of manuals and audio visual tools.
In a pioneering effort, the Trust trained the doctors at the PNC to identity, treat and
thereafter follow up on the progress of mentally ill patients. Thus, apparently for the
first time a PHC in the state addressed mental illness. The Trust was innovative in
utilizing all effective government resources to improve conditions of service in the
community. Hence, it also established contact with the National Institute of Mental
Health and Neuro-Sciences (NIMHANS) who provided both training for a group of
local health workers as well as regular treatment.
Thus, within a few years of its establishment by early 1990s the Trust had clearly
evolved a process of responding to local health needs through its own professionals
and para professionals as well as supporting the state run PHCs to perform better.
These were however, small projects, ad hoc and localized in nature, covering a
cluster of about 50 villages in Yallendur Taluka and implemented with the support of
various individual and small institutional donors and technical support from private as
well as government specialists located in the capital city of Bangalore.
4.1.2 Move to Narsipur Taluk, Mysore District: widening scope of relationship
In 1996 the Trust expanded its area of operations to cover T Narsipur Taluk in
Mysore district, North West of Chamrajnagar. The Trust’s decision to expand to this
taluka, was primarily based on the fact that even though the taluka received
adequate government funds they were not being utilised properly and hence
remained under developed. The benefits of the programme were not reaching the
poor so the Trust adopted a strategy to bring the community and the government
departments together. Community organisations and capacity building became the
key focus and not only was the scope of activities widened to include education,
25
livelihood, etc., but the Trust also began to interact with other government
departments. Again, funds for the Trust’s activities were initially largely generated
from an NRI (Non- Resident Indians), with roots in one of the project villages. Over
the years the projects at Yallendur and Narsipur developed into separate integrated
projects where although health was at the core of the Trusts interventions, livelihood
and education also were addressed.
4.1.3 Takeover of the Gumbaili PHC
In the same year (1996) the Trust also took the next significant step in its evolution
as well as its partnership with the State: it began to manage the Gumbaili PHC and
its’ 5 sub centres catering to a population of 20,000 living in 15 villages, where the
Trust has been active for some years. The population indudes both tribals and non tribals. The fact that Gumbaili was a backward area with no health services was the
reason why the Trust chose to work here. Besides, although a PHC had been
proposed here by the government for some time, it had not as yet been established
and the community had to depend on the poorly equipped sub- centres or travel a
distance to the nearest government hospital. The Trust, which had been running a
clinic in this area since the last few years offered to manage a full fledged PHC.
Although the then existing national programmes had scope for contracting NGOs for
various activities related to programme development, implementation and
management under a Grant in Aid system, there was no provision for allowing an
NGO to manage a PHC in its entirety. However, the Trust realized that the World
Bank supported India Population Project (IPP IX) had scope for innovation and
submitted two5 proposal for Honnur and Thithimathi in March 1995 to the DH&FW for
undertaking the management of a PHC on an experimental basis. Both the proposals
were finally approved in March 1996 in a meeting chaired b the Secretary, DH&FW
and the Trust was allowed to establish a PHC at Honnur. The PHC was being run
out of a rented building at that time but a decision was taken at the meeting to
construct a new building using the IPP IX funds and hand it over to the Trust for a an
initial period of ten years. It was also decided that grant in aid would be provided to
the Trust, with the government meeting 90 percent of expenses out of the ZP budget,
while the Trust would manage the remaining 10 percent. However, whenever drugs
would be supplied the budget provisions will be accordingly reduced. The existing
government staff in the PHC was to be withdrawn and relocated in other areas while
the Trust would employ its own staff, however with no liabilities on the Government.
As the proposed arrangement was a deviation from normal practice, the approval of
the sate Cabinet was obtained before handing over the charge of the new PHC to the
Trust. The project was titled as the’ PHC Handing-over Project1 and this was one of
the 50 PHCs which the government proposed to hand over to NGOs at that time.
(Proceedings, dated 08.06.95)
However, subsequently the Trust apparently changed its decision and opted to set up
and manage a PHC at Gumbaili, as Honnur would not have benefited the tribal
population who the Trust’s primary target. (IDPAD, 2006). This decision was also
facilitated by the fact that when the concerned ZP (Mysore district, under which
Yellandur Taluk was located before bifurcation) was consulted regarding the
proposal, while it gave its concurrence, it suggested that a new PHC may be opened
in Gumbaili for the scheduled tribes and handed over to the Trust. The government
therefore agreed to the change and launched its first collaborative management of a
5 The second PHC at Tilhimathi m Virajpet TahA of Coorg district is being managed by the Vivekanada Foundation, a federation of
12 voluntary organisations, including VGKK and headed by Dr. Baslasubramaniyam
26
government PHC in Gumballi in 1996. Incidentally, as the Trust was at time in the
middle of constructing its own building for its activities, it offered to use this to run the
PHC and the offer was readily accepted by the Government6. Moreover, since this
was a new PHC additional grant was provided under IPPIX to equip it with furniture.
(Proceedings, dated 11.03.96)
Over the next few years several health programmes, community dental care and care
of epilepsy, diabetes, hypertension and mental health were integrated into the
primary health care activities of the Gumballi PHC as by then the Trust had adopted
the concept of comprehensive care recommended at the Alma- Ata conference in
1978. By 2001 the Gumballi PHC had evolved into a relatively mature integrated
model of promotive, preventive, curative and rehabilitative care wherein equitable
distribution of health care through free services and medicines, community
participation, appropriate health technology through integration of traditional and
Indian system of medicines and a multi- sectoral approach was the key strategy. The
PHC in Thithimathi, although not technically under the Trust, also developed along
similar lines and benefited from the support provided by Sudarshan and both
continue to work under the partnership format till today.
Fig 3: Karuna Trust: Evaluation of relationship with Government of Karnataka in
Management of PHC
Characteristics of the relationship
Director heads key policy
making txxfies/oammittees
at state/nalional level
Establishes credibility
through self funded leprosy
control programme
KT invited to set up similar
PHC models in other states
GoK contracts NGO for
district wide leprosy
eradication programme
Formalisation of contract
with GoK to pilot district
level management of health
services
Informal support to local
PHC to meet health needs
Facilitates community
participation for
effective utilization of
state health resources
Formal contract to
manage GumbhalR
PHC
Expansion of
interventions & PHCs/
invitation to manage
PHCs in other states
2007
1987
NGO Outputs
Reduction in
incidence of
Leprosy in
onedstncl
Meeting local health
needs/ introducing
adcfitional health
services
Improved
management
ofPHCs
4.1.4 Expansion of partnership
For the next few years there was no expansion of the Trust’s PHC management
portfolio. However, in 2001 the Trust was handed over the management of two clinics
being run by the Visweswarayya Vidyut Nigam Limited (WNL), a subsidiary of
Karnataka Power Transmission Corporation Limited, located in the south east of
Karnataka in the district of Mandya. These clinics, catering to the staff as well as the
6 This is apparently the only PHC which is at a distance of only 3 KM from the Taluka (Block) headquarters as against the norms of
distance and coverage laid down by the government.
27
local, largely migrant population, were not running efficiently and the Trust took it
over under an agreement with the WML Subsequently, the Trust also agreed to
manage two adjacent government sub- centres which were not running efficiently.
Permission for this was granted by the DHO who had the authority to do so.
It was not until June 2003 that the Trust reached another milestone when two more
PHCs were handed over to it. Subsequently more PHCs were added every year and
today the Trust is managing 23 PHCs, 2 PHUs and 2 clinics across Karnataka. In
2005 the Trust went across to length of the country to the North Eastern State of
Arunachal Pradesh where it entered into a contract with the State Government to
manage 9 PHCs and 36 sub- centres falling under it covering 9 districts, as part of a
pilot programme involving a total of 16 PHCs and 4 NGOs.
The expansion in 2003 and thereafter was made possible by a policy decision of the
Government of Karnataka to hand over 100 PHCs to NGOs and private medical
colleges in the first phase under the ‘Scheme for involving private medical colleges
and other agencies in the management of PHCs’ launched in 2000. The scheme had
provision for NGOs, reputed Trusts or private agencies to either manage a PHC fully
or just to contribute to the improvement of facilities- the Trust has opted for full
management. Discussions with Project Coordinator of the Trust however, indicated
that there has been some debate within the NGO regarding the model to be adopted.
The Project Director had reservations about the ‘Adoption System’ where any agency
could monitor a PHC on payment of Rs. 25, 000, because it was difficult to manage
the government staff that had to be retained. The director of the Trust however was
of the opinion that NGOs should work with the Government staff. However, since
there were great difficulties in working with the government staff, the Trust continues
to largely depend on staff appointed by it.
In the initial days the DH&FW apparently handed over 50 PHCs to various NGOs,
Trusts and private medical colleges. Subsequently however, many of these either
dropped out of the project or their contracts were terminated because they failed to
meet the requirements. Thus so far the DH&FW has not managed to meet its target
of a 100 organisations primarily because most NGOs do not have the capacity or
additional resources to manage a PHC or are weary of engaging with the
government because of allegations of corruption, red tapism and delays. (Director in
interview). The Trust thus remains as the NGO with the largest number of PHCs
under it
However, since 2006 it has deliberately not expanded the list of PHCs in Karnataka
as the purpose was to establish one in each district as a model and not to be coopted into the system or expand the management of PHCs. In fact, at the time of
the interviews the Trust was on the verge of successfully concluding negotiations to
take over the management of the primary health care system in 4 districts on a pilot
basis. The Trust would be initially funded by two institutional donors ( Deshpande
Institute and the Ashoka Innovators) in this venture and thereafter intends to
negotiate for the use of NRHM funds, a strategy that it consciously follows.
Looking at all the factors that went into setting up the relationship, it is evident that
the Trust itself, and more specifically the director, have played a critical role. In fact it
was the Trust that initiated the process of partnership and negotiated with the
Government of Karnataka. The first formal call for such a partnership was apparently
made at a meeting of SCOVA or the Society for Coordination of Voluntary Agencies
in Karnataka, of which the Trust was also a member. The issue was taken up from
there by the Trust and various levels of officials as well as the community- including
the members of the district and taluka panchayats were consulted. What however,
28
appeared to have facilitated the process is also the interest of the Government itself,
who found it difficult to manage remote PHCs with poor infrastructure and a shortage
of qualified staff. At the same time, the Trust was able to meet the additional funding
requirements of the partnership and sustain interventions because it was able to
raise funds from individual and other donors who are mostly settled out of the country
but have their roots in the Trust’s area of operations. In fact the Non Resident Indians
have been instrumental in funding improvements in infrastructure, money for which is
generally difficult to come by.7
4.2 PERCEPTIONS ABOUT THE PURPOSE OF THE RELATIONSHIP
4.2.1 NGO’s perception: support and effectively utilise government resources
There were two reasons that compelled the Trust to take a decision to enter into a
partnership with the state to manage the PHC: The first, as indicated by the director,
was the realization that by running parallel schemes to the government, ‘...we were
only duplicating resources when the government actually had resources and
infrastructure available with them...’; and the second was the difficulties that the
Trust itself faced in continuously raising funds from private individuals and donors:
‘We had to beg to get money from donors...’(director, Trust). Besides, even though
there were several programmes and provisions for redressing the problems of the
poor in all the districts, they were ineffective in many districts.
The Trust realized that managing ‘micro- level interventions’ and establishing parallel
facilities would only solve the problem of poor services to some extent and scaling up
to larger levels itself was restricted due to resource limitations. The Trust therefore
felt that it was more prudent to utilize the vast but inefficiently used government
infrastructure to upscale and improve services and also bring the state and the
community together on to a common platform and thus started work with the state in
the PHC in Gumballi.
There is no ambiguity in the Trust’s statement that it is not running the PHC’s for its
own survival but for improving the system and hence would not like to compromise
on issues of ‘equity, integrity and quality’. Besides, as the Trust does ‘... not want to
take more money and do more and perhaps better work if it is not replicable...’ it has
opted to work within the given working conditions and constraints faced by the PHCs
in the State ‘...including less money but focusing on better outcomes.’ 8 (Sudarshan,
interview). This implies that the models that it develops are adaptable to the given
environment and not designed to work only in a simulated framework.
At the same time however, the Trust does not want to be co-opted into the
government system and prefers to remain autonomous. The Trust would rather be a
partner to trigger change and improve policies, systems and institutionalize the
processes than collaborator only in implementation. The director of the Trust himself
believes in a partnership between the state and the private sector, and observes that
his own role as a key member of various Commissions and Committees at the state
and National level is also a form of PPP that contributes to policy changes.9 Although
he acknowledges that the for- profit private sector does have a major role to play in
7 During field visit to the SuganhalH PHC. m uangalore (rural) district it was observed trial apart from contributing to substantial
upgradafion of the PHC txitfding. a mmber of other community facilities had been provided by a local family, now based in USA, and
al these facilities (PHC, school, library, etc.) were named after the family created Foundation-KRS Foundation
8 However, there appears to be some contradiction here and that is the fact that as an approach the Trust replaces the existing
government staff with its own contacted staff, instead of improving the performance and accountability of the former
9 Al present Sudarshan is also trying to propagate the concept of PPP at the district level through his position as a member of PPP
Task Force constituted by the Planning Commission, Gol
29
the delivery of health services and that in Karnataka 90 percent of the ambulatory
care was being managed by the for- profit private sector, the not- for profit sector or
the NGOs were more critical to ensure equity, integrity and quality of service.
However, the reality was that at the moment they only accounted for 3 percent of the
services.10
The director believes that the government and NGO have ;...two extreme
perceptions about each others value ‘... while the government thinks that it works
best and all NGOs are bad the NGOs think that everything that is ‘government’ is
corrupt...But the truth lies in between.’ In fact many NGOs do not want to work with
the Government because of corruption, red tapism, delays in decision making and
fund flows and general loss of business. But this is again a situation which needs to
be addressed and resolved for while ‘...technical package can give only a small
percentage of benefits, good governance will do better*. He also adds that the
general opinion in India is that basic services like primary health care should be the
responsibility of the public sector. The Trust on the other hand believes that
‘...partnership is an integration of ideas and activities and that total privatization is not
possible.’ On the other hand they believe that over the years they have been able to
facilitate bringing about a paradigm shift from a ‘...medical model to a social
model...a model that is multi sector and integrated...’ (director, interviews with the
author).
4.2.2. For DH&FW partnership is a matter of convenience...
Within DH&FW the understanding of the purpose of partnership is mixed. Most of the
officials at the state level view the partnership as a matter of convenience and a
policy imperative which will be sustained in the future. In fact the Commissioner,
DH&FW stated that Karnataka was a progressive state and that they were keen on
community involvement and would go forward with a PPP strategy in management of
PHCs. He added that NGOs would be involved in the training of ASHA for which the
Trust and another reputed private hospital would take the lead. Besides, under the
12th Finance Commission a trauma care would be provided in each taluka with 2
drivers and 2 nurses outsourced as a mobile unit. On the other hand at the district
and block level, while some see an advantage in terms of availability of staff and
innovations, others are of the view that the partnership does not add any value to the
performance of the PHC.
The Director, of DH&FW while stating the official position on the partnership indicated
that the PHCs were being handed over to ‘reputed’ NGOs because the government
itself had great difficulties in managing remote PHCs and recruiting adequate staff.
This was a reason also echoed by some of the officials in the districts, who observed
that there was a shortage of staff in the Government as recruitments were made only
once in 5 or 6 years. The Trust, they observed, was on the other hand able to recruit
doctors at a lower salary and fill up most of the vacant posts, especially in the PHCs
located in remote areas, thus benefiting the local community. However, they also
observed that management of PHCs was not a profit making and viable option for
NGOs, and therefore most of them did not venture into this field, unlike the Trust,
which was more focused. Besides, even in the Trust, because of the low
remunerations and the difficult working conditions, the attrition rates were high and it
was generally able to recruit only retired doctors (Interviews with THO, Yemallur, EXAdministrative Officer, Jagallur).
10 In fact Sudarshan is also not averse to a system of general practiboner as established under the NHS service in UK and is of the
view that they should also work under a PPP framework
30
Some of the officials at the district and taluka (block) levels believed that there were
other advantages in entering into a partnership with the Trust. They conceded that
the doctors recruited by the Trust were generally more committed and the work in the
field also tended to be better managed because of the availability of ANMs as well as
better monitoring. The presence of the Trust also lightened the burden of supervision
on the government staff at the block and district level. Besides, NGOs like the Trust
facilitated innovations and new strategies, while ‘...creating an atmosphere of healthy
competition.’(DHO Timkur, THO, Chamrajnagar)
However, there were others who were convinced that the partnership with the Trust
was the result of ‘political pressures’ and the influence of the director of the Trust and
the outcomes were not impressive (DHO Devengari). They observed that the stated
purpose of PPP is to improve the quality of services, but this had not happened in the
case of the Trust, except for the introduction of tele- medicines and the setting up of
village resource centres. In fact the performance of the OPD had also not apparently
improved. Interestingly, a key reason for this alleged poor performance, they stated,
was the lack of capacity and management of the medical staff employed by the Trust
Not only was the staff not approved by the government, but often they were not
appropriate. They not only lacked knowledge but were also not suited for the specific
responsibilities assigned to them.11 Although they conceded that the fact that the staff
stayed on the premises of the PHCs managed by the Trust was encouraging, it had
not led to much improvements in services (THO, Jagalur). Besides, most of the NGO
managed PHCs focused largely on the curative aspects and did not adequately plan
and implement the National Programme. The fact that the NGOs were trained by the
Government as part of the partnership was interpreted to imply that the Government
was more qualified and hence there was no relevance in handing over PHCs to
NGOs. Besides, one of the THO’s also opinioned that ‘...NGOs do not have as much
of commitment as the government. They are also not so bound by requirements../
(THO, Jagalur). They concluded that although the Trust was operating relatively
better, there was nothing’ extraordinary’ in their performance. (DHO Timkur).
4.3 Formal rules and contracts
The partnership between the Trust and the DH&FW for the management of the PHC
has been formalized through a simple government order in the case of Gumballi and
a contract, backed by elaborate terms of reference, in the subsequent PHCs.
4.3.1 PHC Handing Over Project: Based on Government Order
The process of formalizing the agreement between the Trust and DH&FW for the
handing over of the Gumballi (and Thithimathi) PHC took exactly a year from the time
the former submitted an application for the same. During this period, as mentioned
earlier, there was a major change and the original proposal to manage the PHC at
Honnur was dropped in favour of setting up and managing a new one at Gumballi.
Accordingly, an order to this effect, duly endorsed by the State Finance Department,
was passed by the GoK (executed in the name of the Governor of Karnataka and
signed on his behalf by the Under Secretary, Health and Family Welfare Department)
on the 11th of March 1996 and communicated to the Trust. This then was the formal
basis of the partnership.
11 Two cases were dted by the THO of Jagakir that of a Staff Nurse discharging the duties of an ANM and a retired Medical Officer
managing the PHC. While the Staff Nurse is not expected to have aiy knowledge atxxA the national programmes or experience in
field work, the MO would not have an wderstanding of the reporting processes.
-
7”
---■
/
-----X
The order had the following primary clauses:
• A new PHC at Gumballi along with the sub- centres attached to it was to be
handed over to the Trust
• The building under construction by the Trust will be used as the PHC building.
■ 50 percent of the management cost will be borne by the State together with
an additional grant for furniture (from IPP IX budget) as this is a new building.
• While the government will sanction the required staff; however, the Trust will
be responsible for appointing its own staff subject to the approval of the
DH&FW.
- The CEO, ZP will sanction the grant to the Trust in the form of 90 percent
grant-in-aid.
■ The arrangements were to hold for a period of 5 years.
Besides, in an annex, the order also laid out some conditions for financial control.
These primarily included the authority to ‘...inspect the style of working and accounts
of the organisation,’ and the proviso that the state would not sanction pay scales that
exceed the pay scales given by the state government. Besides, the Trust was also to
‘strict!/ follow the minimum educational qualifications prescribed by the state for
specific posts. Interestingly, however, at the request of the Trust, the required
qualification for ANMs was relaxed to a minimum of grade 7, as it was impossible to
find more qualified women at that time amongst the tribal population. Other then this
no specific guidelines were issued for implementing the project but a high powered
committee was set up to monitor it, as it was a pilot initiative with potential for
expansion.
4.3.2 Scheme for involving private medical colleges and other agencies in the
management of PHCs: Scheme document and contract
In the second phase, when the partnership was formalized on a larger scale with
more NGOs and private medical colleges, besides the Trust, a relatively elaborate
document was prepared indicating the eligibility criteria for agencies and the
procedures for submission of proposal as well as the evaluation and selection
process. The document also included guidelines for management as well as
‘adoption’ of the PHC by the agencies, the responsibilities of the agencies,
stipulations regarding the assets of the PHC, funding and fund flow for the
government, co-ordination and monitoring as well as provisions for financial control
and audit.
The contract itself is a one page document to be executed by the Director H&FWS on
behalf or the Governor of Karnataka and the concerned agency, although the funds
are released by the district The contract specifies the name, place and location of the
PHC and SCs and commits the agency to abide by the clauses as laid down in the
Scheme document ‘in consideration...’ of the financial commitment made by the
government. Besides, the contract also indicates that the government will ‘reimburse’
the amounts to the agency for the services specified in the Scheme document on a
quarterly basis. However, the services have not been defined in detail and only
broadly refers to the implementation of the National and State health and family
welfare programmes and the primary health care services that are delivered through
the PHC and its sub-centres. It also instructs the agency not to charge any patients
any amount for ’... diagnosis, treatment and drugs or for any other purpose except in
accordance with the government policy.’
Thus, as per the document, the Scheme allows NGOs, Trusts and charitable
institutions as well private medical colleges to either fully manage or contribute
towards the management of PHCs (infrastructure and services). The PHCs are
32
grouped into two categories according to their level of performance with the first
category being that of the top 50 percent of the better performing PHCs and the
second category that of the bottom 50 percent of the poor or non-performing ones.
According to the document 100 PHC in the second category were to be handed over
to selected NGOs etc., for management on a first come-first-served basis. The
Scheme was to be reviewed after two years and the guidelines revised accordingly.
Only those NGOs or Trusts working in the rural areas and are legally registered for a
minimum of three years under Societies Registration Act or similar State Acts, or
Indian Trust Act (1982), or Religious Trusts Act(1920) are eligible to participate in
the scheme. Besides the NGO should be reputed, should have been working in the
same district for a minimum if two years, should be financially sound and should not
have been a defaulter in the use of government funds. Similarly conditions were also
laid down for medical colleges and Trust run by corporate bodies.
The document indicates that the NGOs are to submit the proposal to the
Commissioner H&FWS12 through the Chief Executive Officer of the concerned ZP.
However, each agency, excepting for those backed by corporate organisations, could
apply for only one PHC in the first Phase, perhaps to ensure that they have the
financial capacity to sustain. Although the Scheme was launched in 2000, the Trust
itself entered into a contract under it only in 2003 with two PHCs and thereafter
added an average of 6 PHCs in the next three years. A selection committee headed
by the Commissioner H&FW, and also including a member from SOSVA, has been
constituted to ensure a fair selection. The selected agency is accordingly informed by
the Director H&FWS and thereafter enters into a contract with the later. The agency
is ‘entrusted’ with the management of the PHC for a period of 5 years, but is to be
‘...reviewed and confirmed../ after two years. The agency is evaluated in the fifth
year and renewal of contract thereafter is based on performance.
The document also lays down some modalities for the management of the PHCs,
and states that the agency has to take full responsibility for adequate staffing of the
PHC and its sub-centres in accordance with the staffing pattern, norms and
qualifications laid down by the government. Besides, the staff would be employees of
the agency with no liability on the government. The government itself will withdraw all
its’ staff, although some of them could be retained on deputation, based on mutual
consent The agency is also required to provide inform the DH&FW the details of
remuneration to the staff. If any of the staff appointed by the agency proceeds on
leave of over 15 days, a stand in arrangement ahs to be ensured. The services of the
staff employed by the agency will be terminated automatically once the contract with
the agency comes to an end.
While the existing assets of the PHC are to be handed over to the agency at the time
of entering into the contract, the agency is also allowed to add to the assets but at no
cost to the DH&FW. The agency will also have to provide the details about the assets
added to the Directorate. These assets, together with the government assets will
have to be handed back to the Government on the termination or closure of the
contract. The agency also has to ensure that adequate stock of essential drugs are
maintained and dispensed to the patients at no cost.
The DH&FW on its part will reimburse the costs as per specified norms that include13:
Staff cost at 75 percent of the salary paid to government staff at the minimum
scale.
12 At that tine the Directorate of Health and Family Welfare was known as the Diedorate of Health and Family Welfare Services
13 The annual government budget for a PHC in Karrataka is Rs. 12 Lakhs whereas m AP it is Rs.27 lakhs. However, unlike in
Karnataka the government AP is particular that the Trust stands by its commitment to contributing towards 10 percent of the salary.
33
Leave salary for up to a maximum of 30 days per year
Maternity leave salary for up to a maximum of 90 days per delivery and
restricted to two deliveries in the service period. POL charges to a maximum
of 100 litres a month if the agency has an exclusive vehicle for the PHC
Full reimbursement of water and electricity charges to a maximum of 1500
per month
Rs. 25,000 annually for maintenance of the building
Funds (at present Rs. 75, 000) for drugs as per the scale fixed by DH&FW
Funds will be released on a quarterly basis by the District Health and Family
Welfare Officer (DHO) from the district sector on approval of the ZP.
Another reason for the government to include a 75%-25% funding clause, besides
ensuring cost sharing, was to initially put of all and sundry NGOs clamouring to
manage a PHC and also to stop politicians forming NGOs and then lobbying to hand
over PHCs to them. Apparently, the State has recently agreed to give 90% percent
costs but the order is yet to be executed.
According to the Scheme document, the District Health and Family Welfare Officer(
now known as the DHO) is to monitor the working of the PHC in terms of the services
that it is required to provide within the framework of the various National and State
Health and Family Welfare programmes and the ‘...provisions of the general Health
care services in the PHC as per the general directions of the Government.’ (GoK
Scheme document, 2000).
In order to ensure effective coordination between the agency, the DHO and the ZP, a
coordination committee consisting of the Commissioner H&FWS, CEO of the ZP,
Chief Accounts Officer & Financial Advisor and the Additional Director (PHC) was set
up. The government has also given itself the right to issue directions to the PHC in
specific circumstances. The authority for issuing directions however has been vested
with the Director of H&FW or officials of a higher rank.
Finally while the Scheme document audits it also allows the Government to terminate
the contract for violations of the conditions of contract, after due enquiry. The agency
also has the right to terminate the contract after a 60 day notice period. Sudden
termination without notice by the agency is likely to attract penalties equal to the
budget amount for the period.
Thus although the contract document gives some directions for control and the
agreement describes the relationship as a contract, holding the Trust to perform the
tasks as laid down under national and state programme mandates, some of the
clauses indicate that there are elements of horizontal collaborations as it gives
freedom to recruit own staff and expand activities and facilities with just intimation to
the government. Besides, it also implies that the NGO will bring in additional
resources to improve both facilities and services.
5. THE RELATIONSHIP IN PRACTICE
In practice the dynamics of the relationship between the Trust and DH&FW is
reflected at two levels: At the state level there is general willingness of decision
makers to continue with the experiment as a potential strategy for managing remote
PHCs; and on the other hand at the district and taulaka levels, there is a range of
reactions from perceptible reluctance to placid acceptance or active support. While,
some see it as an unnecessary intrusion by an agency that is allegedly unable to
perform better than the government, others are informed enough to appreciate the
34
advantages that the NGO offers. There are also a few who simply accept it as one of
the many projects of the government which need to be implemented according to the
rules. Obviously then there are operational dynamics, which impact on the
partnership and it various from district to district What also becomes obvious is the
fact that the influence of Sudarshan at the state and national level appears to have
infused strength into the relationship.
5.1 Operation of the relationship
5.1.1 At the State level
Although the intensity of interactions between the state and the NGO is significantly
greater at the Taluka and district levels, it is at the level of the Directorate and the
Department of H&FW that policy decisions to launch, sustain and change the
relationship are taken. And here, interviews with various senior officials indicate that
although operational problems, and at times even issues related to performance do
exist, the concept of partnership as well as the Trusts commitment, integrity and
better performance is well recognized and acknowledged. The director of the Trust
states that the Trust ‘....has alliances within the government with people who
understand the process and we know that they will support us.’ (director, interview)
While this ‘understanding’ has emerged from an informed and extensive debates,
discussions and research at various levels and forums, the Trust’s confidence it self
has emerged from having demonstrated viable models while not compromising on its
commitments and integrity.
In fact, it is evident that the Trust had a role to play in initiating the partnership
process for the management of PHCs as far back as in 1996. While, Sudarshan was
a key person in not only the negotiations with the DH&FW, but was also instrumental
in identifying a way forward to locate the initiative within an on going project (IPPIX).
The Trust consulted all the stakeholders, primarily the communities and although
most of the communities were agreeable to the proposed arrangement, one of the
gram panchayat (Yeragamballi), encouraged by local private doctors and others with
vested interests, tried to block the proposal on the pretext of it being a stepping stone
privatization. The issue was eventually resolved after prolonged meetings and
dialogues with the members and the community in which the director of the Trust
himself participated. Eventually, it was the community that sent a written request to
the Government to allow the Trust to run a PHC at Gumballi.
The Trust also supported the DH&FW to obtain approval from the Finance
Department which was reluctant to hand over government PHCs to NGOs.14 The
Finance Department was eventually convinced, when DH&FW, backed by the Trust,
mooted a cost sharing arrangement with NGOs, in which the Department would be
able to save money. In fact, the director of the Trust himself was invited to participate
in a high powered meeting in June 1995 chaired by the Secretary of the DH&FW to
finalise the handing over of two PHCs and also apparently contributed to the drafting
of the modalities for the subsequent scheme that was launched in 2000. The Trust
could also convince the State to subsequently hand over the Gumballi PHC instead
of Honnur. It is interesting to note that here the Trust strategically mobilized support
of local leaders including the local MP, and ZP, Taluka and GP members for effecting
a transfer. Besides, the fact that at that time only the Trust and the Vivekanada
Foundation, which was again an NGO with which Dr. Sudarshan was associated,
were the only two in the programme, indicates the extent of credibility and influence
that he carried.
14 The State was also apprehensive that politicians may open NGOs with no commitment, when they saw an opportunity.
35
But this is not to say that the Trust does not have to face a fair share of scrutiny and
criticism from the state officials. The Director, H&FW, explained that there were two
aspects to PHCs - i.e. the promotional and preventive functions monitored under the
National Programmes and the curative function. He observed that, while NGOs have
discharged their curative responsibilities effectively, many of them have failed to
deliver the former responsibilities, and the Trust was also facing the same gap in
implementation, although it performed well on other scores. According to him a major
reason for this could be the shortage of staff, especially ANMs, with adequate
capacity. In fact about 6-7 NGOs had to withdraw from the project because of poor
quality of staff and lack of performance. NGOs were unable to attract adequately
trained and experienced staff because of the low remunerations. The Trust, like other
NGOs and medical colleges participating in the programme is subject to periodic
reviews and evaluations by the DHO and third parties and has also been had also
been advised about the lack of training of its staff and perhaps this and the shortage
of ANMs was the reason that it has set up an ANM training institute with license from
the state.
5.1.2 At the operational level
Handing over the PHC: Vested interests and iack of information were initial
hurdles
The Trust is aware that while ‘The top level is happy with (its) performance...the
district is at times not happy.’ However, the Trust is convinced that given time and
inputs, the government run PHCs, with its backward and forward linkages at the
District level, can also improve its performance ’... But ...vested interests at the
district level ...are acting as hurdles.’ (director, interview).
There are several functional areas where the Trust and the THO and the DHO offices
interact. For instance at the time of taking over the PHC; for specific support like
training for its staff, organising health camps, support in the case of a disease
outbreak, etc.; in review and monitoring; and in the release of the agreed drug supply
and budget. And how smoothly these functions flow depends to a large extent on
attitude of the concerned THO and DHO and the relationship between them and the
Trust run PHC.
The first point of interface is the process of taking over of the management of a PHC.
The process is long drawn and requires sanctions and feedbacks from several
layers, including the elected local body or the ZP.
The process of obtaining approval for taking over the management of a PHC is long:
■ The Trust submits an application to a central committee at the State level;
• The application is forwarded to the Zilla Parishad (ZP) in whose territory
potential PHCs are located;
• The ZP sends its comments to the District Health Officer (DHO), who will
then shortlist 2-3 PHCs to be adopted
• The ZP then gives its final comments which are thereafter forwarded to the
State government.
• Once they get an order from the state government the Trust takes the order to
the Taluka Officer (who is often surprised but complies). Together with the
Taluka Officer an inventory of equipment, stock, etc. are made and books of
account signed off. The Government staff may choose to stay or be replacedwhich is what happens in most cases.
The whole process takes anything from 2-3 months and even longer if any of the
concerned stakeholders oppose the move. Often there is initial resistance from two
quarters: the community and its representatives as well as the government staff at
36
the PHC, THO or DHO level. At times it was a case of the government staff
instigating the community because of vested interest and sometimes it was the
community itself reacting to the unknown and unfamiliar. Their fear is centreed round
the belief that the advent of the NGO would lead to ‘privatization’ of the PHC,
consequently making it inaccessible to the poor, a left wing’ concept, as the director
of the Trust puts it. Some of the ZPs also fear a loss of control when the PHC
management is handed over in its entirety, although they are not averse to NGO
involvement in the implementation of individual national programmes like
immunization, AIDS-HIV control, etc. Some of the ZP members also had a more
narrower interest regarding the authority of the Medical Officer of a NGO run PHC to
issue medical certificates, especially for medico-legal cases (only a government
officer designated as ‘Class I Gazetted Officer has the authority to issue such
certificates). A few of the takeovers, like the ones in Thithimathi, Coorg and Kadugu
have been really difficult with community leaders in some cases even taking out
agitating against the move in public. In fact, some of the senior managers indicated
that initial resistance from the community was the rule rather than an exception.
In the case of the DH&FW officials in some of the talukas and districts the resistance
was due to vested interests or lack of the right information. Corruption, as indicated
by state commissioned reports, is rampant in ‘epidemic’ proportions in the health
sector in Karnataka: in delivery of services by staff from ward boys to doctors and
specialists,15 in various services -from the time of birth to death- offered by the PHCs
and government hospitals termed as the ‘life cycle approach to corruption’,
corruption in civil works related to the health sector, in health administration and
finally corruption in medical education ( Sudarshan, 2006). Against this background,
it is not surprising that doctors, para- medics and administrators posted in these PHC
for long years feel threatened and deprived of their ‘under the table income’ when the
Trust takes over the management and the existing staff is either relocated to other
PHCs or has to opt to work with the NGO at reduced remunerations. Often, the staff
who feel threatened, instigate the community with notions of ‘privatisation’ and
takeover.
The Trust however, dismisses these as ‘teething problems’ and adds that they
continued to stand by their values and ‘...do not compromise.’ (meeting with senior
management of Trust). It feels that this situation arises because of a tremendous lack
of understanding at the PHC and district level in turn due to lack of effective and
informed communication from the State. It is also partially because of the fact that the
PHCs handed over to the Trust are also the most difficult ones.
Almost always the Trust eventually manages to come out of seemingly impasse
situations with the community. Such issues have so far been addressed through
intense dialogues between the community and its leaders and the Trust- with at
times, even the chief functionary of the Trust participating in the dialogues. There
have also been instances when the DHO (Chamrajnagar) has intervened to assure
the community and ZP that the government was only temporarily ‘renting’ out the
PHC to the NGO to ensure service delivery. What is significant is that once the Trust
has established a rapport and credibility with the community, the later often become
an ally in furthering the agenda by donating land for additional facilities for the PHC,
contributing or raising funds for buildings, staff quarters and other facilities, using
their influence to negotiate with higher levels of the government- even up to the level
of the State- for additional resources and facilities for the PHC. The Trust therefore,
15 'For instance the Medical Officer gives money to the Taiuk officer as a regular feature Al this gels affected with our kind of
approach' (Sudarshan, Interview)
37
routinely informs the GP/ ZP members about activities so that they do not create
problems. The two factors that encourage the GP/ZP them to do so are the
commitment of the staff, the almost complete absence of corruption in the PHC, the
on campus presence of medical professional 24 hours in the day and also the
relatively more humane response to their needs.
In the case of the government staff from the PHCs, THO and DHO, the impact is
reduced or dies away once the community is agreeable to the new arrangement. In
fact, the community then takes up cudgels on behalf of the Trust when required or
then the director himself has to request the State to intervene and to allow the Trust
to takeover the PHC. However, often the hostility from the taluka/ district level
officials continues in different ways, even after the Trust has formally taken over the
management of the PHC. Sometimes, the resistance is also due to lack of
information or wrong notions. But this is cleared soon after the partnership actually
begins to function. In fact one of the THO (In-charge, Kalam), observed that before
the partnership was initiated in one of the PHCs under jurisdiction, he and his
colleagues believed that it was not good move as the Trust would hire its own staff
over whom the THO would have no control. But now they think otherwise.
There are other staff related issues that also arise at this stage. One is the problem
of managing excess government staff from the Sub Centres who are handed over to
the Trust together with the SCs. In many cases the Trust negotiates with the DHO,
and sometimes also mobilizes the DH&FW, to redeploy them to SCs under some
other PHC. However, such relocated staff from the SCs still continue to draw
salaries from the Trust managed PHC, with consequent administrative implications.
In the initial days the Trust also realised that there were some unwanted posts in the
PHCs, like that of a First Division Clerk, with little work. The Trust negotiated with the
State and converted the FDC’s post to that of an Administrator, who worked was
employed for the full time . Thus, the Medical Officer in charge of the PHC was
relieved of much of the burden of administration, freeing time for community work.
Such flexibility was also visible in other aspects of manpower planning and
management within the partnership. For instance, the DH&FW also recruited and
positioned staff on behalf of the Trust in the PHCs. This involved transferring
additional posts from other PHCs and recruiting staff that were then paid by the
Trust. In some cases the State recruited as well as paid for the staff.16 The
government also passed orders allowing the post of the Medical Officer to be filled by
CAMS or Ayurvedic doctors. But such arrangements, whereby doctors work with the
Trust but are paid by the government, at times causes problems, as the doctors
report to the DHO and hence their allegiance is often divided.17 Another hurdle is
that some of the State appointed doctors find it difficult to relate and interact with the
THO and the DHO in the same manner that an NGO appointed doctor would do,
indicating the obvious play of hierarchy and subordination. Even in the case of ANMs
appointed and paid by the State, management at times becomes difficult, especially if
the ANM is powerful or is a political appointee.
16 In the PHC at PatnayakHalli, one ot the lady doctors (Laxmi) is on a transferred government post but paid by the Trust, while the
second lady doctor (Somya). has been recruited by DH&FW and posted here on an Additional Doctor’ post She is also pad by
DH&FW
17 The Progranwne Director of the Trust reported a case of an Additional Doctor posted in one of the PHCs who was constantly
causing problems and reporting late for duty. The Trust has warned him that he would have to leave if his performance did not
improve.
38
Conducting business
Once the PHC has been handed over and the initial hurdles resolved the Trust has to
ensure that services, i.e. the national programmes and regular primary services, as
stipulated by the State are delivered effectively. It was obvious that the Trust has
considerable freedom to organize and run the activities within the PHC and also add
to the services and facilities, however at its own cost. In the process of conducting its
business however, it has to interact with the offices of both the THO and the DHO for
procuring drugs on a periodic basis and for release of funds from the State,
channelled through the ZP and the DHO. From time to time the Trust also seeks help
for specific purposes like organising health camps and at times of medical
emergency. Further, the Trust’s activities are also monitored by the THO and the
DHO.
Ensuring quality of services: In reality, to a large extent the Trust relies on its own
staff and on various types of collaborations with other private institutions for
improving the quality of services and providing additional services. For instance, it
has tie ups with a renowned hospital located in Bangalore for heart related
treatments and, as indicated earlier, has established a system of regular
consultations through its telemedicine facilities or acquires the services of specialists
for short term and on voluntary basis. Occasionally the Trust has to seek the help of
the THO/DHO and reportedly such help has been usually forthcoming. For instance,
in the case of the PHC at Patnayakhalli, in Tumkur, while the Tubectomy cases are
referred to the Taluka Hospital, Cataract camps are organised in collaboration with
either the district hospital or a private hospital. Similarly, the THO, Yemallur stated
that his office and team provides support whenever help is requested. The THO also
involves the Trust in the health camps that his office organizes and provides training
in health education.
Procurement of drugs: The more regular interactions between the Trust and the
THO/DHO are primarily for the release of funds and procurement of drugs. Rs.75,
000 worth of drugs is delivered annually to each PHC by the state, out of which 60
percent is purchased on the basis of a general indent and decentralised procurement
and 40 percent through the State Drugs and Logistic Society. The reason for this
arrangement apparently is to ensure that the essential drugs are available in the
PHCs because, as often some MOs do not indent for these. While some of the Trust
managed PHCs complained that there were delays in procuring the supply of drugs
as well as gaps in the quantity supplied one of the PHC also reported that the
concerned staff in the DHO’s had tried to extract bribe from the Trust. While one of
the DHO’s admitted that there were delays and shortfall in the drug distribution
system and that this was largely due to bureaucratic failure, he also observed that
the NGOs needed to understand that the government was very hierarchical in
decision making and hence often the DHO may have genuine reasons for delays in
responding to the request of NGOs (DHO, Chamrajnagar).
Thus it is obvious that the Trust does not have any say in procurement as apparently
the government rules are rigid on these issues. However, it has tried to respond to
these problems by evolving its own system of additional procurement on one hand
and trying to influence the state to improve elements of the system. Thus, a
significant percentage of the drugs are procured by the Trust - through LOCOST and distributed at its own cost to all Trust managed PHCs. For instance one of the
PHCs (PatnayakHalli, Tumkur) reported that in the year 2006-07, the Trust had
supplied almost Rs. 300,000 worth of drugs. The Trust, therefore often ends up
spending its own money. Besides, the Trust has also facilitated the state to prepare a
list of essential drugs for mandatory distribution to the PHCs. It is also advocating for
indent based supply of drugs and although the order to this effect has been passed
39
by the government it is being complied only by some districts. Apparently, localized
procurement of drugs has helped to some extent and the lag time has been reduced.
But problems still exist: for instance drugs go missing, wrong kind of drugs are
supplied at times and of course there is corruption.
Release of funds: The release of funds is also a cause of some tension between the
Trust and the DHO at times. The budget itself is agreed with the state and funds are
released by the DHO but on the approval of the ZP. Under these conditions delays
occur from a minimum of one month to a maximum of even 10 months if the Trust’s
relationship with either the ZP or the THO/DHO is not very conducive to
collaboration. In the early days of the partnership there were apparently occasions
when the Trust was also asked to pay a percentage of the funds as bribe for
releasing the money. But the Trust has managed to resolve this by firmly refusing to
comply and at times formally using its influence at the State level. Delays however
continue and the Trust is able to cover the expenses without disrupting the activities
of the PHC, only because it is able to raise additional private funds.18 The Trust
attributes these delays ‘...to the process adopted by the system and the still
prevailing corruption. Bad management is another reason.’ (director in interview).
Earlier the reimbursements from the DHO used to be routed through the Bangalore
office of the Trust. However, because of complaints from the PHC about late
payment of salaries, etc., an account has been opened in the name of the MO and
the Administrator of the PHC and the funds are deposited into this account. The Trust
has provided a rotating fund to start of the process and while some DHOs have
already initiated the process others have agreed to start it in the new financial year.
The Trust has managed to recently negotiate with the state and correct this to some
extent by instituting a process of monthly reimbursements. The Project Director
indicated that there was also great rigidity in the way the budget lines were defined.
For instance although the contract allowed for some amount of funds for POL, some
of the PHCs could not access this amount because either the PHC did not have an
ambulance and a driver or in some cases had the post of a driver but no vehicle!
Again the Trust, through its own resources has been able to procure a vehicle for
some PHCs. Then again, although there is a budget for administrative costs, there is
no provision for training the staff. Therefore the Trust has to rely on training offered
by the DHO or on its own funds. It generally chooses to do the later.
At times, the Trust also has difficulties in accessing specific programme funds. For
instance it reported that the Janani Surakhsah Yojana (an amount given by the State
to every expectant mother to encourage institutional delivery) could not be accessed
till the director of the Trust approached the officials in the DH&FW. The Trust was
denied the use of these untied funds because they were a “private entity’. The fact
the Project Director of the Trust is familiar with the functioning of the State because
of his previous experience as an employ of the state, also helps.
Monitoring and review: The THO by virtue of its position is responsible for the direct
monitoring the PHCs run by the Trust The planning and reporting system according
to the Trust is cumbersome because there are almost 20 formats to be generated
from the PHC to the DHO level. Besides, the ANMs are required to maintain 13
books of records and 18 formats.
18 Apparently, the Trust lias already spend over Rs. 4000,000 on drugs and other expenses in the
current year, which was yet to be reimbursed at the time of the interview's.
40
The Trust is required to report on a monthly basis to the DHO through the THO, who
requires programme-wise information to be submitted on prescribed formats,
common to both the NGO as also the state run PHCs.19 There are also regular
monthly review meetings conducted by the THO at the taluka level and in which the
Trust run PHCs are also required to attend. The MO attends some of these meetings
while all the ANMs and their Supervisors are expected to attend all the monthly
meetings. At times separate meetings are also held for specific programmes. While
some Trust managed PHCs reported cordial and supportive relationship with the
THO during the monthly review meetings, some like the PHC, Mallapura complained
of either being ignored, as it was an NGO run PHC and hence not perceived to be
the responsibility of the THO or were actually given ‘step- motherly treatment’ and
humiliated. The THO or his team only visited the PHC once in a month instead of
more often as required. They were also apparently not provided with the requisite
training and this was the reason why the ANMs could not perform better vis a vis the
national programmes. Those who were supportive were generally the THOs who
realized that as the PHC was their responsibility any good or bad performance would
reflect on their own ability to deliver (MO, Yemallur PHU).
In most of the districts the MOs are not required to attend the monthly meetings
organised by the DHO (these meetings are primarily held with the THOs of the
district). Therefore, the MOs of the Trust managed PHCs interact only at special
meeting a few times a year or when the DHO or his team visits the PHC. In the case
of Gumballi PHC under the Chamrajnagar DHO, the ANM/Health Supervisors also
meet with the DHO once a month. However, this is a district specific case instituted
on the initiative of the DHO for several reasons: apparently it helps in keeping up the
moral of the Supervisors; it enables the DHO to communicate what is important and
urgent; it facilitates the DHO to become aware and understand the grassroots
problems; and it allows the DHO to monitor cash flow and ensure necessary checks
and balances in case any MO in the PHC (both State and Trust managed) is not
performing according to requirements (DHO, Chamrajnagar). The DHO also ensures
that at least one Programme Officer participates in the monthly meetings at the
THO- in fact this seems to be a practice followed by other DHOs also as indicated by
the RCH Officer of Devangari District. He stated that the DHO also has adequate
Interactions with the NGO. The Programme Officers from the DHO thus maintain
their contact through the monthly visits to the PHCs, review meetings at the DHO as
well as THOs, district level ICDS meting with the THO, quarterly meetings with the
MOs, as well as workshops from time to time.
The PHCs are evaluated at the end of the stipulated period by a third party
commissioned for this purpose. Currently, the evaluations are carried out every year
by a joint team consisting of the DHO, District Surgeon and the Women and Child
Welfare Officer of the district.
Levels of satisfaction: While many of the THOs and DHOs were satisfied with the
overall performance of the Trust managed PHCs, some of them were unhappy about
the concept itself. For instance the DHO in Chamrajnagar has a good rapport with
the PHC and appreciates the work done;20 on the other hand although the THO
perceives the PHC to be an NGO one does not create any problem. The director’s
influence in this area is very strong because of the long years of presence as well as
19 The Trust run PHCs however generate additional formats (7 in number) which is then submitted to Trust office tn Bangalore giving
management and structure related infconation Besides, the Trust has also constituted a supervisory team consisting of the MO, AO
and the Senior Health Worker to provtde and overview of the critical ONA survey undertaken by the ANMs based cn which a number
of activities are planned
20 In fad Sudarshan was influential in posting the current DHO here and both appear to have a mutual resped for each ether
41
the work done here. It was also reported however, (DHO, Chamrajnagar) that
although the ZP did not object to NGOs implementing specific projects, it only had
confidence in the Trust and would not allow any other NGOs to manage the PHC.
Others, like the Director IPP, who monitors the Yemallur PHU was happy with the
innovations in the PHU and carried out only minimal supervision, as she thought that
the Trust was capable of running it without much supervision. This was also
corroborated by the concerned THO. However, he was of the opinion that in order to
make the partnership work better, there should be a better understanding between
the community and the NGO.
Those who were strong in their criticism of the Trust (THO Jagalur and DHO
Devengar) apparently were unhappy with both the concept of PPP as well as the
Trust itself. According to them poor performance was observed in several areas
including in the Patient Department, the number of in- patients who were treated, the
low numbers of deliveries conducted in the PHC, poor performance in immunization
services and lack of knowledge about immunization schedules. ‘I do not think that
KT has made any difference. The fact that the staff stays on the premises of the PHC
is good but this has not led to much improvements in services. ’ (THO, Jagalur).
They attribute this condition to several factors including a lack of knowledge about
various national programmes, not having the right people on the right job, high rates
of attrition - perhaps because of low levels of remuneration, etc. The THO, they
complained, was left to just function as a ‘post office’ within the partnership because
the staff from the Trust went to the THO/ DHO only for reimbursements and not
advice. ‘They do not come to the THO to enquire about programme and discuss the
difficulties they face... The PHC does not refer to the Taluka Office, we do not know
what drugs they have received...referrals are in fact very poor (Official of the THO,
Jagalur). Stating that they were not satisfied with the overall work, one of the officials
also alleged that the NGO managed to get funds from the government because they
were influential and ‘powerful’. In fact the THO did not have any control over them
and instead the Trust put ‘pressure ...from all sides’.
However, the Trust pointed out that often the DHO itself was not willing to take
decisions that were within its authority, and the Trust had to resort to the State,
perhaps giving the impression that it had overstepped the authority of a lower level
official. For instance some PHCs have a large number of SCs spread over a vast
area and become difficult to manage{ In Bijapur and Tumkur there are 11 SCs each
spread over 80 KMs). This requires some amount of reorganization of the SCs and
connecting it to other PHCs- a task that is within the jurisdiction of the DHO. But the
DHOs wants the decision to come from the state and therefore the Trust took up the
issue with the Director- H&FW, who has in turn asked the Trust to submit an
application together with a map showing the current and proposed locations and
attachments of SCs.
The DH&FW as well as the DHOs were aware of these tensions between some the
Trust run PHCs and the DHO/THO, and attribute it to bureaucratic systems, lack of
information and a belief amongst some of the officials that these PHCs are not their
responsibility because they are run by a private entity. However, they also clarified
that at no time do they excluded the NGO run PHC because PPP does not mean
excluding such PHCs. They also do not give it a step motherly treatment and
‘...review the NGO PHC with equal responsibility because anything good or bad
about that PHC reflects on the DHO’ (DHO, Tumkur). However, they observed that
they had no systematic control over these PHCs like they did in the case of the
government managed ones. It was also stated that the decision to continue with the
partnership arrangement with any of the PHCs was taken at the state level and that
42
the DHO could only recommend about continuation. On the other hand the DHO and
the THO were accountable for the health status of the community across all PHCs
and in case of any health related emergency then the health department is blamed.
6. EFFECTS OF THE RELATIONSHIP
6.1 Effect on the partner organisations
The Trust and the DH&FW entered into the partnership with similar goals- of
ensuring equity in the delivery of primary health care services. For the Trust this was
translated into empowerment of the rural and urban poor, especially the tribal
communities, through integrated development with better health care services as a
core strategy. Besides, the Trust’s aim of effectively using the state resources
instead of running parallel systems has been achieved because it is able to access a
large percentage of the cost of running the PHC. For DH&FW on the other hand, the
goal of health care with equity, like all government agencies with a larger mandate to
service all the communities but with a provision to ensure that the poor and the
marginalised are not excluded, implied improving the services of the poor performing
PHCs. As such the relationship conforms to the individual goals of both the partners,
without in any way effecting the overall ideologies and identities.
Having said that, in terms of functional relationship at the implementation level, the
bureaucratic system, and more so the pervasive corruption within the institutions of
the THO and DHO, poses a challenge to both efficient operations as well as
institutional internalization of innovations and lessons. While the Trust does not feel
that it has to compromise on its values, ideas and identity, a sense of imposition of
the relationship exists amongst some of the THOs and DHOs. While this is due to a
variety of reasons- partially vested interests and partially lack of information- it does
make the process of the relationship that much more difficult, especially for the Trust.
Hence, for the difficult THO and DHO the Trust is more a thorn in the flesh or an
irritant that cramps its style and authority in the area, whereas for the more
accommodating district or taluka level agency the Trust takes off some of its burden
of work.
Considering that the Trust’s relationship itself varies from active participation to
resistance or passive engagement, the overall impression is that the Trust has
considerable freedom to take forward its own agenda. The factors that make this
possible are the influence and credibility of the organisation and more so its leader. It
is also because of the autonomy that it gets through the additional resources it is able
to generate to not only to upgrade facilities but also to provide a back up when funds
from the government are delayed or is inadequate. Besides, the fact that most of the
PHCs handed over to the Trust are in any case the difficult and remote ones limits
interference on a day to day basis to some extent.
6.2 Effect on the agenda
Over the years the Trust has been able to bring about some policy level changes
having an impact on the operations. For instance, it assisted the state to prepare the
list of essential drugs and also influenced them to become flexible and change the
norms of allocating a fixed annual amount of Rs. 75, 000 per PHC for drugs,
irrespective of the patient load. At the time of the study the Trust was also negotiating
with the state to hire contract doctors and depute them to the PHCs managed by it in
order to meet the shortage of doctors. Overall, the chief executive of the Trust
(Sudarshan) has played a key role in shaping the health sector in the State, primarily
43
through his contributions as a Task Force Member and the Chair of the Committee
appointed to draft and oversee the implementation of the health Policy. The fact that
a number the recommendations of the Task Force and the integrated Policy reflects
elements of the Trust’s learnings is an indication of the extent of the formers ability to
influence. The director of the Trust observes that he considers his role as a member
of the state Task Force, and a Vigilance Officer in the Lok Ayukta and the chair of the
PPP at the national level to be forms of public private partnership: ‘I consider all
these roles as another form of public- private partnership and that partnership is
being affected at various levels.’ He also is of the opinion that issues like influencing
the state to change the norms for allocation of funds to the PHC are also the impact
of PPP.
As far as a model of NGPA in partnership with the state is concerned, the Trust has
been able to demonstrate a model which is a shift from a medical to a social model
and where community is central to the strategy. It now does not therefore feel it
necessary to expand to more PHCs and instead intends to move up to the higher
level of the district.
What seems to be missing here, however, is a concerted and visible effort and
process either on the part of the state or most of the districts to imbibe lessons from
the experience of the Trust. What is also disconcerting is the fact that though the
Trust itself has been able to advance its activities across Karnataka and even other
states, in Karnataka itself there are very few NGOs who have opted to enter into
similar relationship with the state. In fact, the state has been unable to achieve its
original goal of handing over 100 PHCs in the first Phase. The director of the Trust
attributes this to the reluctance of many NGOs to engage with the Government for
fear of red tapism and corruption. However, the DH&FW is of the opinion that most of
them either lack the capacity - both in terms of skills and resources - or are
themselves too corrupt to sustain the relationship. Therefore, while the Trust itself
has been effective in taking its agenda forward both in terms of coverage, depth of
activities and influence on policy, there is a gap in terms of confidence and
acceptance of the approach amongst the various stakeholders.
7. CONCLUSIONS
The relationship between the Trust and the DH&FW is informed and cordial at the
level of the state but generates a mixed response at the implementation level. It is a
relationship that has been clearly pushed by the Trust in the initial stages and well
accepted at the policy making level. However, the tensions at the operational level as
well as the hitherto, almost single focus on the PHC, has perhaps limited its impact,
although it has been successful as a model of an efficient PHC responding to
community needs. Perhaps, its forthcoming experiment with partnership focusing at
the district level health care services may address these problems.
The role of the leader in not only initiating the relationship, but also in taking it
forward and integrating it into the health policy of the state as well as at the national
level comes out clearly. It is one of those classic cases where the NGO has
strategically moved from demonstration models to impacting at the state and national
level.
The relationship reflects a horizontal collaborative model, although based on a
loosely structured contract. It gives relative freedom to the NGO to contribute both in
terms of resources and ideas.
44
LIST OF INTERVIEWEES
1. Dr. H.S. Sudarshan, Director Karuna Trust
2. Dr. Deb, Project Director, Karuna Trust
3. Dr.Prashanth, Field Coordinator, Karuna Trust
4. Manjunath, Manager, Head Office/ Administrator, PN Hulli PHC, Kanina Trust
5. Staff of PatnayakHalli PHC, (Karuna Trust managed)
i. Dr. K. Sheshagiri Nayak, Dr. In- charge
ii. LMO,
iiLAdministrator,
iv. Lady Doctor,
v. ANM
6. Staff at Gumbahlli PHC ( Karuna Trust managed)
i. R.N. Sharma, Manager
ii. Dr. K. S. Sharat, Medical Officer
iii. Jeshri, MHW/ Supervisor
7. Taluk Panchayat Member, BR Hills
8. Hindi Teacher, of the school run by VGSK in BR Hills
9. Yamallur PHU (Bangalore Urban District)( Karuna Trust Managed)
i.Dr. Rema Marar, MO,
10. PHC Mallapura ( Karuna Trust Managed)
i. M.V. Hosur, M.O
ii.Venkatesh, Administrator
iii. Usha, Staff Nurse
iv. Anand Kumar, Pharmacist
v. Surya Prabha, Female Health Worker, Anapur SubCentre.
11. Mr. Basvraja, Commissioner, Health and Family Welfare, GoK
12. Dr. M.B. Rudrappa, Director, Health and Family Welfare, GoK
13. Dr. Vishwanath Kumar, DD MCH, GoK
14. Dr. Buwaneswari, Varathur PHC, Bangalore, GoK
15. Nanja Reddy, Health Inspector, Varathur PHC, GoK
16. Dr. Shapatti, DHO, Chamrajnagar, GoK
17. Dr. K.S. Mamata, Director IPP Hospital, GoK
18. THO, YemallurGoK
19. Dr. Shivparakash , Ex Administartor, THO, Jagalur, Devengare district
20. Bharat Bhushan, THO, Jagalur, GoK
21. Dr. Shakarappa, Jagalur, GoK
22. DR, Arvidam, DHO, Tumkur; GoK
23. Dr. Gandhi, Malaria Officer, Tumkur, GoK
24. Dr. Ranganath, In charge THO and Medical Officer of Kalam, GoK
25. DHO, Devengari, GoK
26. Dr. Muawar, RCH Officer Devengare , GoK
27. Pawan Kumar, an MBA graduate recently appointed as Manager under NRHM
(District Programme Manager), GoK
28. Thema Reddy, Community Leader
29. M.R. Shobha, husband of one of the GP members
30. K.R. Hanumant Rai, G.P Member
31. PatNayakHalli, GP meeting
32. GP members
33. S.K Ramma Reddy ZP member, Mallapura (Hiremallenkote Panchayat)
45
REFERENCES
Das Gupta, Shangon and Ghanshyam, Bharathi ; Anubhav- Experiences in health
and community development: Karuna Trust; Published by Voluntary Health
Association of India, October 2006
Government of Karnataka (2001); Karnataka: Towards Equity, Quality and Integrity in
Health; Final Report of Te Task Force on Health & Family Welfare, April 2001
Government of Karnataka (2005); Karnataka Human Development Report, 2005
IDPAD case No.5, Management of Primary Health Centres by Karuna Trust,
Gumballi and Suganahalli, Karnataka (www.south.du.ac.in/fms/idpad/case-studies)
Karuna Trust; Annual Reports 2004-05; 2005-06; and 2006-07
Narayan, R. (2001); Review of Externally Aided Projects in the Context of their
Integration into the Health Service Delivery in Karnataka; CMH Working Paper Series
WG6: 8; March 2001
Planning Commission, Gol, 2006 Draft Report on Recommendations of Task Force
on Public Private Partnership for the 11th Plan
Radermacher.R, Putten-Rademaker. O.V., Muller. V, Wig. N, and Dror. D (2005);
Karuna Trust, Karnataka, India: CGAP Working Group on Microinsurance; Good nad
Bad Practices, Case Study No. 19
Sudarshan. H;(2006) The ‘Epidemic’ of Corruption in India; www.karunatrust.org
Vijay. K, Express Health Care Management; Issue date 1st to 15th June 2003
46
Primary health care and public-private partnership: An indian perspec...
file:///G:/Arogya Banditti Schente/Primary health care and public-priv
ORIGINAL ARIK 1.1.
Year : 2009 | Volume : 2 | Issue : 2
Page : -46-52
Primary health care and public-private partnership: An indian perspective
Ranabir Pal1. Shrayan Pal -
MDeP.ar^DuJ ^l?ry,1l,> Me(1ici"e- S'^'”1-Manipal Institute of Medical Sciences (SMIMSt and Central Kefernl
Hospital (CRH), oth Mile, ladong. Gangtok. Sikkim - 737 102. India
(Citi
Knb"r7iliSIl; Sikk™;“:’"ipi" lnsli"lle '" Medical Sciences (SMIMS) and Central Referral Hospital
(CKI I), 5th Mile, ladong, Gangtok, Sikkim - 737 102. India
Click here for correspondence address and email
Dale of Web Publication
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J AnicJis
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Abslraci
deleSXnd: w l’ie new.,nil|en,;ium-llle Pro^ess
success of primary health care (PI IC) in India has been
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"ldeXed ll,erallire and website-based population survey reports; 13 states with public
p" w' X om mn I'1'M
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Cri,eri0" t0 defilie bolfl
and’noXp^
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5 akui Outcome variables were success of PPPs in PI IC implementation. Results: I he studs criticalh
rev ewed PPPs m the hght of their services in the PI IC segment and significant policy perspectives by an <n depth
as sodal e\ ilX‘X7,|helbeTf,l\ll,C “7
a“d ,linc,ll,n,"^)l lh^ ^mcs. In the health sccior PPPs in India
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b^' features ol the two mergutg authorities of Government and prix ate sccior fhex have ’
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Keywords: Public private partnership, primary health care
How to cite this article:
Pal R. Pal S. Primary health care and public-private
2009;2:46-52
partnership: An indian perspective. Ann Trop Med Public Health
How to cite this I Rl.:
Introduction
iS£Ei~==i===S:
mental, and social well being . Io approach health for all. the world's nations together with Wl l() I INI 'l l md
^orcant.tmns. pledged to work towards n.eet.ng people's basic healtl. tleeds^r^^^Xsiee
Pkt^l on lite development ol tnfrastruetnre techniquesand manpower for service delivery mallv in rural areas'
:H—...
overall comprehensive urban slum development. I'J
.... ........................................................ —
I Of5
......?:"?“■...
sXhX£ns^
than 70% of curative care In I Jttar Pradesh of tlr^u IIKrtaSI'1g °Vt.r ,lie yei"S- the Pnva,e sec,or nou provides more
Uttar I radesh. of the women who seek care for renroductive health nroblem. 7| % seek
24-03-2016 14: ■
Primary health care and public-private partnership: An Indian perspec...
file:///G:/Arogya Bandhu Scheme/Primary health care and public-priv..
levels of health care as key partners to success in implementation. NRI IM has contemplated that involving the private
sector as part of the RCII initiative will provide more effective health care delivery system. I2) The number of private
sector institutions and dependence on them has been increasing over the years: the private sector now provides more
than 70% ofcurative care In I liar Pradesh, of the women who seek care for rcproducliw health problem. 71 % seek
care from the private sector. 14
India has, since independence, developed a huge health care infrastructure in both public and private sector (including
voluntary organizations).
Apart from the for-profit private sector for health care, the non-governmental organization (NGO) and voluntary sector
have also been providing health care to the community. More recently. PPPs have been attempted to involve the
private sector in delivery of national health programs and in drug development Some ol the initiatives in India include
improving access to PHC services. 1’4 There are a few important issues in PPP. like choice of model for shared
investments and operating expenses and lime frame for contract, delining a formula for shared revenues lot a Ian
contract; estimating volume growth is tricky. There are many sources ol revenue.: we can charge the client (utility,
service provider or citizens) or generate from advertisements-building. transaction slips. Legal and policy hamewoiks
which encourage PPP arc authentication and security of private partner transactions, design of service level contract
(obligations onall partners) and ability to enforce as PPP model can create another type of monopoly. Conditions that
foster reform are strong political driver and seasoned civil servant executor- In high risk projects (innovations) presence
of both is ideal, political support is required to end monopoly provision of services by departments and tackle vested
interests and civic pressure plays a limited role in initiating the project
I lowevcr. civic pressure is critical in preventing a rollback of reform. Media plays an important role in minimizing
resistance from vested interests and in motivating the staff enabling policy framework and legal environment that
encourages civil servants to be entrepreneurial. I•4
I bis article tries to analyze the progress and success of PHC in the new millennium when, due to different reasons, not
only secondary and tertiary care but also PHC is delegated to and nurtured in the hands of growing number of
'for-profit' and 'not-for-profit' PPPs.
Materials and Methods
Study design
Retrospective study design based on systematic review' of primary health care was appraised on an extensive collection
of studies, including meeting presentations and personal communications, from different sources in which PPPs were
reported.
Literature search for data sources was done through an extensive search in indexed literatures and website- based
population survey reports. Thirteen stales were identified where public-private partnerships are working on primary
health care found in thirty potentially relevant articles.
All published articles in indexed journals available from various institutional libraries of India and websites on PPPs ~
were included in this study. Studies have also been identified by searching Pubmed-enlrez and abstracts from scientific
meetings. Rex iews of citations and reference lists helped identify additional eligible studies I he search terms included
PPPs and PI It Sources were contacted (wherever possible) for further information on survey data not readily
available in the public domain Manual searches were conducted from review articles and previous meta-analyses. We
also contacted authors for additional information or translations from languages other than English
Selection criteria
We developed a broad criterion to define both 'tor-profit' and 'not-for-profit PPPs.
Study design
Retrospective study design based on systematic re\ lew ol PPP on PHC was done by an extensive array of data. We
attempted the comprehensive, annotated assembly of survey results from different sources; published surveys and lield
studies in which PPP on PHC were reported, meeting presentations, personal communication on recent surveys not
included in previous analyses. Sources were contacted for further information on survey data not readily available in
the public domain
Review criteria
Standard nomenclatures based on information provided in the publications b\ the global experts have been used.
()uiconie variables
Success of PPPs in implementation of PI IC
Results
In an ideal PPP. in the health sector, the newly created entity pools the best features of the two merging authorities.
Various state governments in India have been experimenting partnerships with the private sector to reach the poor and
underserved sections of the population. PPPs are increasingly seen as an important mechanism for improving PHC.
Located in rural and urban areas, the health services studied included mobile services, general curative care, maternal
and child health services, community health financing activities, health promotion activities. We examined how the
rolesofa common shared vision, strong governance, and effective management inlluence a partnership's ability to
achieve its objectives.
of 5
24-03-2016 ’
25
Drimary health care and public-private partnership: An Indian perspec...
file://ZG:/Arogya Bandhu Schente/Primary health care and public-priv.
and child health services, conmiunily health financing activities, health promotion activities. We examined how the
roles of a common shared vision,
.
strong governance, and effective management influence a partnership’s ability to
achieve its objectives.
the tmdings, based on both qualitative and quantitative analyses, underscore the importance ol membership
mw'tTt'°"S pe,rce|lv^ be"el"f! ai,d cosl "''PMicipation and management capabilities Io the partnership's progress
Gronn nfH It, r
’
p"v:"e Parlnership initiatives are currently under implementation in tlj Maniftal
Ganetok Sikk m
e
pr'SeS lnCludl"e ^ktrn-Manipnl University of Health. Medical and Technological Sciences.
In lhe array of these forms of partnerships, (here is little evidence to indicate the relative merits of one form of private
w7l''iefov ■' 7 r'd
’ 7'7 'yPeS orol’eri,lic™1 iss‘les
management and policy perspectives on
I. A
ou V«.» Ol diem IS needed belore any specific analysis 'Gontracline'(conlracline 'oul' and W) was lhe
predommant model o pnvate partnership. Other two forms ol partnerships re. soctal Iranchtsmg and soe.al marketmg
commer" S
' ''e privalC SCC'"r WBS rePrcsei’'ed
'n™ of individual phvsicians
commercial contractors, large private and corporate super-specialty hospitals and NGOs.
Some of the partnerships deal with simple contracts (diet, laundry , cleaning, etc) while others are more complex
p'irbe shim'll S'akehoiderS < Yeshasvtm. a community based self financed health insurance scheme). In alnuist all
3eiS PU I
Partner 'S 7 dep3nn’ent oriK;",h a"d
^Ifare. either state or central, directly
tliiough health facility level commntces. In terms ol (he monetary value, the least valued contract was in providin/
die ary services at a rate ol Rs. 27 per meal for about 30 meals a day (Bhagajalin hospital Kolkata) The oldest
CTurameevi sei’"0 7’ “ "’e ad0P"°" i'"‘l "1;l":'gen1cnl l’rP™™ry health centers in Karnataka bv Karima Trust The
Xd Xt o frl 7 (e"8ai8lng pr'Vi"."..doc,ors ror ^'iveries) in Gujarat is lhe newest of the initiatives (since Dec
200:). Mos of the projects are specific to a geographical region while some benefit an entire stale (Yeshasvini
scheme).
I he role ol tndividuals in the initiation and success oI PPP is vers crucial. For example in the case of Arpana Ssvisihv,
Kendra the project director ol Arpana Swaslhya Kendra worked hard Io convince the political leaders and
'' ‘
healthcenlre'todi X N1Unlc,pai CorPora"‘>" "I'l^lhi. lor approval Ibra proposal to hand over the corporation
health centre to the NGO under an agreement In the case of Yeshasvini scheme, founder and d,rector of N-tnvnna
proitT There
,V'
ly pl<lyed 3 Cr"ICil1 role sc"in« "P lhe Karnataka Integrated Telemedicine and Tele-health
d e nrimlX V 7'™ '’7'' Pe™"3l''ics
P-’ieet too. In the case of adoption and managemem o
peoplX Col Pam 7
i'T"“7
?rDr- Sudharsl,an liom Kal™a T™sl
crucial. Similarly initiatives of
people hke Col. Ian (Lt aianchal mobile health clinic). Dr. KJR Murthy (Mahavir Trust Hospital) Mr M A Wohab
<Boat based moh.le health servtces in Sunderbans). and Dr I laren Joshi (Shamlaii I lospital (mjarmZe msZd
diX' h’'^n 'l DI CS' Cl,'""'-"anug:"'- 3 P’^'m’iinamlv tribal uihabued dtstrict. had only primiuv care lactllties in lhe
In lhe case of Karnataka and West Bengal, the stale level policy on r ”
public-private partnership was framed after
launching few pilot projects. In the case of Tamil Nadu. Rajasthan, and (iui'arat ’ the
stale polic) towards the private
wl^rP Par,l7rsh,p(seem have been '""-oduced without any prior experimentation. Tamil Nadu is one such state ’
here private sector involvement in health services was encouraged fora long time especially encouratiine the
industrial houses. It would be fair to say that as of now the policy is virtually hieHective. The slate of Andhra Pradesh
< a positive engagement in health sector reforms, does not have any private sector partnership initiatives of
NGOICKZrkaV,a,e CfdenrV' Governmcnt pa-vs 75% of,lle
cost and the rest is to be mobilized bv the
runm.w
k i n ° 10 "'SI S'aIeS '0 h^1'1 lh'S Schcme for invo1' "’g NGOs and private medical colleges in
™*I i P C 7T Karl"’a " US'":'S "’C rirS' NG< 1hC ha"ded
l-l(h cciuer xvhen m
theCumbulh PHC m Chamarajanagur disir,cl was handed over Io usalier 10 vears ofwork in ihm area on
Leprosy. I uberculosis and Epilepsy l iable l| lxl
Discussion
I rom the analysts ol lhe cases, il is clear that the government grants under PPPs are invariable directed towards
I imarv care services. I liis
his repudiates the claim in some quarters that partnership with private sector would divert
government resources towards tertiary
tertian care services. The argument that pnvate partnership 7 rome » 7
privatrafion does not hold much truth even in lhe primars care sen ices L 7 „
,
"
at these locations without government grants. Therefore government role is indispensabM Thc'"riiic;d"ssu'e 7 PPI'all'
Z.,rem7XX^ft7ZX"";reU!'b,'rSC'!’';''!
P"W
'™d-d
ur respec five strengths and weaknesses, neither lhe public sector nor the private sector alone would be al Ihebesl
deiZ'mX’t .777,PP7'ha! '“"'P—KI help ,n mnehoranng lhe probiem of poor hcalih serv ices
.... "
3 of 5
deXedcounZa Xhod'llb"’ "'''T
. ...ll
7, '’7
s ", ,7’•
■
ttf.H
"'1PIWe
S'l'd> scl,l"gal’d ™"lar '^d“
'«s
rcs,,ureg-"’le"sl''>; structural improvements, but also on cheap.
Ml wn
(nrn(.we)
lt,||v thp nrAlvl|. 11<p of
•
|
24-03-2016 14:23
^rimarv health care and public-private partnership: An indian perspec
Hie: 'G/Arogya Bancihu Scheme ^Primary health care and public-priv...
essential drugs), process failings (non-use of the national case management algorithm and lack ol a protocol ol
systematic supervision of health workers). Efforts to improve the quality in the study setting and similar locales in less
developed countries (LDC) should focus not only on resource-intensive structural improvements, but also on cheap,
cost-effective measures that address actual delivery of services (process), especially the proper use of national
guidelines for case management, and meaningful super ision. Since a majority of the partnership projects has to do with
primary care sen ices, it ?s presumed that quality issues in specific terms may not have been envisaged Opportunities
exist for PPP in a compclilixe environmenl Private institutions may deliver then sen ices al a prolit but al reduced
prices, subsidized or even fully paid for by the government. Similarly, the government may make available products,
such as drugs, for free or at significantly low costs to private providers who serve the poor. There is no shortage ol
ideas to improve the quality of health care delivery, while ensuring access for everyone regardless ol income. I lowever.
only with a global commitment to improving PHC can the present health crisis laced by developing countries be
effectively addressed. Primary health care is a new approach to health care, which integrates at the community level all
the factors required for improving the health status of the population available to all people al the first level ol health
care. In a radical departure from the traditional health care system, it is conceived as an integral part ol the country s
plan for socio-economic development I11!
The National Health Policy 2002 slates. "In principle, this policy welcomes the participation ol the private sector in all
areas of health activities - primary , secondary or tertiary." The policy includes not just private sector companies but also
NGOs. community-based organizations (CBOs). Panchayali Raj institutions (PRIs) and other forms ol civil society.
Conclusion
an administrative decision. An obvious but important point is that it must enjoy political and
Private partnership is t
I is important to understand not only what services are to be provided under private partnership.
communilv support. Il .u ....rv
.
• .
. .
but also the basis on which such decisions are made. We explored the implications ol this research lor future
evaluations of public-private primary health partnerships. One of the core components of PPP is mutual responsibility/
commitment All the partnership projects are expected to provide services under national programs, including
mimumzation, family planning, etc. All the partnership agreements should have clear operational guidelines and specilic
performance indicators for the private partners.
In India, deficiencies of the public health system could be overcome by reforms in the health sector One ol the
important reform strategies is collaborating with the private sector in the form of PPP. Partnership with the private
sector is particularly critical in the Indian context. Due to the deficiencies in the public sector health systems, the poor
in India are forced to seek services from the private sector, under immense economic duress. In the health sector the
PPP as a social entity pools the best features of the two merging authorities of government and private sectors which
have already shown their potential of accountability the people of India. The time has come to explore this to the fullest
extent to promote health ol the common mass in our country.
However, there are not many reports on PPP in PHC. Inter observer bias is possible and hence critical comments on
data presented here are welcome. 111,1
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