BAD MEDICINE

Why is Karnataka handing over a public hospital in Udupi to a UAE company for the next 60 years?

Public-private partnerships have failed to deliver healthcare in Karnataka over and again. What explains the state government's decision?

On August 24, the Karnataka cabinet approved handing over a government maternity and children’s hospital to a company in the UAE to develop into a larger multi-specialty hospital. The company BRS Ventures owned by Indian businessman BR Shetty will be allowed to construct a 200-bed maternity and children’s hospital, a 400-bed super-specialty hospital and an urban community health centre. The memorandum of understanding allows BRS Ventures to run the facilities for 60 years under a build-own-operate-transfer model.

It was only when Karnataka CM Siddaramaiah official twitter handle put out a tweet “A govt hospital in Udupi shall be handed over to Abu Dhabi-based entrepreneur BR Shetty to develop it into a multi-specialty hospital” that the proposed handover became public.

BR Shetty has several business interests, especially in health-related areas. He owns the London-listed NMC Health, UAE's largest private healthcare provider as well as a drug manufacturing company Neopharma. The Karnataka government has also awarded the contract to develop Jog Falls in Shimoga district to Shetty.

Caught between two wrong approaches

Philanthropy, real or disguised, has been the bane of democratization of healthcare. Citizens are caught today between the proverbial rock and hard place. Either they are reduced to the indignity of being recipients of dole and charity or they are expected to be “consumers” in the healthcare “market”. And often, the difference between the two is blurred.

Nowhere is the idea of healthcare citizenship in a democratic Constitutional paradigm articulated. The recent National Health Policy 2015 is a prescription for opening the floodgates of aggressive privatization that seeks to further fragment, weaken and destroy what remains of the public health system. The policy document is unabashed in its celebration of the “healthcare industry” while not even committing to increased allocation for the public health system.

The policy goes on to exhaustively list how it plans to support this industry – lower direct taxes, higher depreciation in medical equipment, income tax exemptions for 5 years for rural hospitals, custom duty exemptions for imported equipment, income tax exemption for health insurance, active engagement through publicly financed health insurance, preferential and subsidized allocation of land, subsidized education of medical personnel graduating from government institutions who work in the private sector and provision of 100% foreign direct investment. Studies have demonstrated that corporate or private sector recipients of such state largesse under public-private partnerships have shown scant respect for the “poor” and have violated memorandums of understanding with impunity with governments unwilling to rein them in.

Spectacular failures

Successive governments in Karnataka have been diligent flag-bearers of various forms of public-private partnerships in healthcare. The government initiated the Arogya Bandhu scheme in 2004 under which ‘C’ category primary health centres – those located in hard to reach areas, those with high levels of maternal and infant mortality rates, those that are more than 15 kilometres away from the highways, those with long-term staff vacancies­ – were handed over to NGOs and private medical colleges supposedly for improving quality and access to healthcare services. The government in January 2016 cancelled the scheme after its own evaluation found no difference in the functioning between the government-run and NGO-run primary health centres.

Similarly the Rajiv Gandhi Super Specialty hospital set up on a 73-acre campus with money donated by OPEC group of nations in Raichur town in Hyderabad Karnataka region was handed over to Apollo Hospital Enterprise Limited for a ten-year period from 2002 to 2011 with a one-time grant of Rs 950 lakhs. An evaluation in 2012 found stagnant utilization rates over the ten years. A mere 44% of beds were functional, there was a drop in bed occupancy from 85% to 58% and a measly 11.42% of beds were allotted to patients from the below poverty line group. The evaluation also found serious financial irregularities and mismanagement.

More shockingly, the proportion of below poverty line patients accessing care had plummeted from 94.7% to 21.4% for inpatient care and from 92.8% to 7.5% among outpatients event though they had been paying higher tariffs than the above poverty line patients.

This evaluation was an indictment of the profiteering interests, the exploitative nature of public-private partnership arrangements that push the most vulnerable to the brink and break down public health systems. While the government has taken back the Rajiv Gandhi Super Specialty hospital since then, the hospital continues to pay reel from the effects of the partnership. Recently the district and session court in Raichur ordered seizure of computer systems, photocopy machine, printers, standing fans, chairs and other materials for defaulting on payment of Rs 36.93 lakhs to a private company for laboratory equipments purchased in 2010 when the hospital was still under Apollo Hospital Enterprise Limited.

Fixing what isn’t broken

Despite evidence of the detrimental effects of this healthcare model the Karnataka government seems determined to pursue public-private partnerships. Further, the proposed handing over of the Udupi government hospital does not fit the government’s prescription for such an arrangement. It is not located in a “backward”, “remote” or “difficult to access” region of the state nor is it part of a poorly performing public health system.

Udupi district tops the state on maternal health indicators. In 2015-2016 the district reported only two maternal deaths. Two-thirds of its facilities are in the “good” and “above average” categories by the government’s own assessment. The fact that the government is keen to sell out a well-functioning, efficient government facility is an ominous sign. It is too naïve to believe that the potential of a government hospital on a 7-acre of prime land in a well-developed coastal town valued at around Rs 300 crores would not have attracted the attention of various business interests including medical tourism.

Predatory private and corporate business interests have captured policy making at the central and state level through unconstitutional parastatal bodies that function beyond democratic control of citizens and have compromised health sovereignty.

Local citizens groups in Udupi and progressive social movements across Karnataka have begun mobilizing and a steady political pressure is being built across the state against the proposed handover. The call to save the Udupi government maternal and children’s hospital should also be a call for all citizens to return to seeking care in government facilities, stake their democratic claim as legitimate owners of the public health system and foster its strengthening.

The authors are activists with the Karnataka Janaarogya Chaluvali, a people’s struggle for health rights in Karnataka.

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Removing the layers of complexity that weigh down mental health in rural India

Patients in rural areas of the country face several obstacles to get to treatment.

Two individuals, with sombre faces, are immersed in conversation in a sunlit classroom. This image is the theme across WHO’s 2017 campaign ‘Depression: let’s talk’ that aims to encourage people suffering from depression or anxiety to seek help and get assistance. The fact that depression is the theme of World Health Day 2017 indicates the growing global awareness of mental health. This intensification of the discourse on mental health unfortunately coincides with the global rise in mental illness. According to the latest estimates from WHO, more than 300 million people across the globe are suffering from depression, an increase of 18% between 2005 and 2015.

In India, the National Mental Health Survey of India, 2015-16, conducted by the National Institute of Mental Health and Neurosciences (NIMHANS) revealed the prevalence of mental disorders in 13.7% of the surveyed population. The survey also highlighted that common mental disorders including depression, anxiety disorders and substance use disorders affect nearly 10% of the population, with 1 in 20 people in India suffering from depression. Perhaps the most crucial finding from this survey is the disclosure of a huge treatment gap that remains very high in our country and even worse in rural areas.

According to the National Mental Health Programme, basic psychiatric care is mandated to be provided in every primary health centre – the state run rural healthcare clinics that are the most basic units of India’s public health system. The government provides basic training for all primary health centre doctors, and pays for psychiatric medication to be stocked and available to patients. Despite this mandate, the implementation of mental health services in rural parts of the country continues to be riddled with difficulties:

Attitudinal barriers

In some rural parts of the country, a heavy social stigma exists against mental illness – this has been documented in many studies including the NIMHANS study mentioned earlier. Mental illness is considered to be the “possession of an evil spirit in an individual”. To rid the individual of this evil spirit, patients or family members rely on traditional healers or religious practitioners. Lack of awareness on mental disorders has led to further strengthening of this stigma. Most families refuse to acknowledge the presence of a mental disorder to save themselves from the discrimination in the community.

Lack of healthcare services

The average national deficit of trained psychiatrists in India is estimated to be 77% (0.2 psychiatrists per 1,00,000 population) – this shows the scale of the problem across rural and urban India. The absence of mental healthcare infrastructure compounds the public health problem as many individuals living with mental disorders remain untreated.

Economic burden

The scarcity of healthcare services also means that poor families have to travel great distances to get good mental healthcare. They are often unable to afford the cost of transportation to medical centres that provide treatment.

After focussed efforts towards awareness building on mental health in India, The Live Love Laugh Foundation (TLLLF), founded by Deepika Padukone, is steering its cause towards understanding mental health of rural India. TLLLF has joined forces with The Association of People with Disability (APD), a non-governmental organisation working in the field of disability for the last 57 years to work towards ensuring quality treatment for the rural population living with mental disorders.

APD’s intervention strategy starts with surveys to identify individuals suffering from mental illnesses. The identified individuals and families are then directed to the local Primary Healthcare Centres. In the background, APD capacity building programs work simultaneously to create awareness about mental illnesses amongst community workers (ASHA workers, Village Rehabilitation Workers and General Physicians) in the area. The whole complex process involves creating the social acceptance of mental health conditions and motivating them to approach healthcare specialists.

Participants of the program.
Participants of the program.

When mental health patients are finally free of social barriers and seeking help, APD also mobilises its network to make treatments accessible and affordable. The organisation coordinates psychiatrists’ visits to camps and local healthcare centres and ensures that the necessary medicines are well stocked and free medicines are available to the patients.

We spent a lot of money for treatment and travel. We visited Shivamogha Manasa and Dharwad Hospital for getting treatment. We were not able to continue the treatment for long as we are poor. We suffered economic burden because of the long- distance travel required for the treatment. Now we are getting quality psychiatric service near our village. We are getting free medication in taluk and Primary Healthcare Centres resulting in less economic stress.

— A parent's experience at an APD treatment camp.

In the two years TLLLF has partnered with APD, 892 and individuals with mental health concerns have been treated in the districts of Kolar, Davangere, Chikkaballapur and Bijapur in Karnataka. Over 4620 students participated in awareness building sessions. TLLLF and APD have also secured the participation of 810 community health workers including ASHA workers in the mental health awareness projects - a crucial victory as these workers play an important role in spreading awareness about health. Post treatment, 155 patients have resumed their previous occupations.

To mark World Mental Health Day, 2017, a team from TLLLF lead by Deepika Padukone visited program participants in the Davengere district.

Sessions on World Mental Health Day, 2017.
Sessions on World Mental Health Day, 2017.

In the face of a mental health crisis, it is essential to overcome the treatment gap present across the country, rural and urban. While awareness campaigns attempt to destigmatise mental disorders, policymakers need to make treatment accessible and cost effective. Until then, organisations like TLLLF and APD are doing what they can to create an environment that acknowledges and supports people who live with mental disorders. To know more, see here.

This article was produced by the Scroll marketing team on behalf of The Live Love Laugh Foundation and not by the Scroll editorial team.