On April 24, Hussain Kodibengre and Siraj Ahmed went to the Madras Records Office also known as Tamil Nadu Archives in Chennai. They were looking for records of the Maternity and Children’s Hospital in Udupi, Karnataka. It was an urgent task because the documents could help them in their fight to save the hospital from being taken over by private interests.

The Maternity and Children’s Hospital is the government district hospital in Udupi. In August last year, the Karnataka state government took the decision to hand the hospital over to Abu Dhabi businessman BR Shetty to be managed by him under a public-private-partnership model. The government is leasing the four-acre plot of land on which the hospital stands to Shetty’s BRS Ventures for a “minimum period” of 30 years which may be extended to 60 years on “mutual agreement”. Shetty has promised to turn the current 70-bed hospital into a 400-bedded hospital, of which 200 beds will be reserved for free treatment of people below the poverty line.

Kodibengre and Ahmed are part of a citizens’ group in Udupi that is fighting the decision and has approached the courts. The Judicial Magistrate First Class on April 18 rejected their complaint against the hospital’s handover saying that the citizens’ group has no locus standi to challenge the government’s decision. The citizens’ group then filed a case with the second divisional magistrate court, a matter which is pending now.

The hospital was built in the early 1900s by Udupi resident, founder of Corporation Bank and philanthropist Haji Abdullah. In 1932, Abdullah donated the hospital and adjoining land to the taluka administration, claims the citizens’ group. However, BRS Ventures argued in court that there are no documents showing that Haji Abdullah donated the land. Kodibengre and Ahmed are hoping to find documents to show that Abdullah owned the hospital land to establish the citizens’ group locus standi as complainants.

“We (the family) do not not have any documents related to Haji Abdullah Sahib’s land now,” said Siraj Ahmed, a banker and financial consultant and also Abdullah’s great grandnephew.

Kodibengre, who is the general secretary of Udupi Zilla Muslim Federation, which works for the welfare of poor Muslims, said: “For two days we dug into the records between 1910 to 1935. We could not find a single record about the hospital.”

Citizens of Udupi fighting against the public private partnership for the Maternity and Children's hospital last October. (Photo: Menaka Rao)

Is change really needed?

Karnataka has a history of public private partnerships for public health but many of these have failed miserably, say public health activists Akhila Vasan and Vijaykumar Seethappa from Karnataka Janaarogya Chaluvali, an organisation of people’s struggle for health rights in Karnataka.

“Once a private entity takes over a public hospital, it brings in its own rules,” said Vasan. “It slowly starts increasing costs and brings in exclusionary criteria. A private hospital always wants (return on) its investments out of the venture. It is not doing this for charity.”

Dr PV Bhandary is a psychiatrist in Udupi who has worked at the district hospital in the past and is part of the citizen’s group fighting the handover.

“We fear that if this model becomes a success (to the point that BRS Ventures starts running the hospital), it will be used everywhere else in the country,” he said.

BRS Ventures' construction site for a 400-bed hospital next to the original district hospital. (Photo: Menaka Rao)

The National Health Policy 2017 espouses both partnerships with private companies to deliver healthcare services as well as strategic purchasing of health services from private players, especially in areas where the public health system falls short. But are public healthcare services failing at the Udupi District Maternal and Children Hospital? Does it fit the criterion for such a change in management?

Low maternal mortality

The hospital is clean and seems well run. There was a water shortage in May, but Matron Violet D’Souza insisted that the hospital was cleaned as it always is. D’Souza does not remember the last time a woman in labour died at the hospital. She had heard that one woman died in their hospital about 13 years ago.

In India, 174 women die for every one lakh live births in the country and maternal deaths at district hospitals are not uncommon in other parts of India.

“There have been only two maternal deaths last year in the district,” said Dr Rohini, district health officer in Udupi. This statistic is remarkable considering that the hospital attends to about 200 women in labour every month, according to senior gynaecologist at the hospital Dr Kishori P. That translates to 2,400 women who give birth to children at the district hospital every year. In fact, Udupi has a lowest maternal mortality rate in Karnataka. Half these women undergo C-sections. C-sections are as performed as often at other district hospitals across India for lack of infrastructure and qualified medical staff.

The hospital demonstrated its efficiency in Rekha Naik’s case. The thirty-year-old woman came to the hospital in early May from Padukone village near Kundapura more than 50 km away. She was unable to walk and was carried to the hospital. She was in an advanced stage of pregnancy and suffered from preeclampsia, a high blood pressure condition that can be a fatal. The doctors conducted an emergency C-section and delivered her twin boys.

District hospitals are the largest government hospitals in a district and get referrals from all over the district. Patients are referred to the Udupi hospital from taluka hospitals and primary health centres and sometimes from other districts too.

“We have a higher percentage of C-section deliveries because most of our patients are referred,” said Kishori, referring to the how their these referred patients often have medical complications. “If there is any risk, we conduct a C-section. We do not even want to allow for perinatal deaths.”

The perinatal period is from 22 weeks of pregnancy to seven days after birth of the child.

Vasan said that the low maternal mortality is a sign of robust healthcare and the hallmark of a good district hospital.

The hospital also has a children’s wing with 20 beds and a Nutrition Rehabilitation Centre to treat children with severe acute malnutrition.

Kenchamma (left) is a migrant farm worker from Baghalkot and lives in Udupi's Nitoor slums. Her 18-month-old son Vasant (right) suffers from severe acute malnutrition and is being treated at the Udupi district hospital. (Photo: Menaka Rao)

The hospital is also located at the centre of Udupi city and is easily accessible to a large number of people. The rapid urbanisation of Udupi has resulted in a large number of labourers from Odisha, West Bengal and north Karnataka migrating to the temple town. The migrants work in paddy fields, in building construction, in fisheries and other industries. The migrant labourers live in shanties in the city and it is this low-income group that is most dependent on the district hospital for medical and health services. The district hospital refers patients to Manipal’s Kasturba Medical College, a private hospital, if it is unable to handle a case.

When asked if the about the hospital’s current performance, Rohini said, “It is a good hospital.” She refused to comment on the handover.

Doubts about the private partner

Despite the hospital’s good performance, the memorandum of understanding signed by the government and Shetty last year says that the 70-bed hospital is in a “very dilapidated condition”, “acutely insufficient to meet the current demand” and “...as it stands the institution is not in a position to respond to the aspirations and the need of local population.” The memorandum mentions that Shetty approached the government for permission to develop the hospital.

“We admit that the hospital needs some repairs,” said Ahmed. “But that does not mean the hospital should be given away.”

The existing Maternal and Children's Hospital which will be demolished soon. (Photo: Menaka Rao)

The hospital staff are worried both about how well the hospital will be run after Shetty’s group takes over and about their own fate. According to agreement with the government, the BRS Ventures will be allowed to hire its own staff to run the hospital. The current staff who are all state government employees will be transferred to other government hospitals across the state.

The MOU states that the hospital will be monitored by a committee consisting of the CEO of Udupi district, the deputy director of health services, the district health officer, the district surgeon and others.

Even though the memorandum of understanding acknowledges that Abdullah donated the hospital land, BRS Ventures’ lawyers say there is no record to show the land was donated.

The only document procured by the group of activists so far is a record of transfer of the land in 1932 from the taluk administration to the erstwhile Madras Presidency. The document lays down the condition that the properties continue to be named Haji Abdullah Dispensary and Haji Budan Lying-in Hospital and that the hospital should “forever” be used to provide free medical aid free of cost. There is still no record that Abdullah owned the hospital and the land.

Document showing transfer of property from the taluk board to the Madras Presidency. Highlighted text shows the conditions laid down during the transfer of the property.

Many Udupi residents continue to support Ahmed and Kodibengre in their hunt for evidence of Abdullah owning the property, so that they can use it to prevent the hospital from being handed over to BRS Ventures. Many of these supporters want to keep Haji Abdullah’s legacy alive.

“We are getting donations (to fight the case) from known people and also anonymously,” said Ahmed. “There are people who are born in the hospital, especially at a time when hospitals were scarce.”

A doctor who works at the district hospital but did not want to be named said: “If the hospital is run in the right spirit, the handing over of the property to Shetty will work. But, this is a good running system. Why do you want to burn your hands? Why kill a running system?”

This reporting project has been made possible partly by funding from New Venture Fund for Communications.