Lalita Malviya is a lady health visitor at a primary health centre or PHC in Ambirama village in Pratapgarh district of Rajasthan. Her job involves supervising three sub-centres, within the area served by her PHC. For the residents of the area, these facilities are their first point of contact with the public health system. A lady health visitor usually has a few years of experience as an auxiliary nurse and midwife, but 25-year-old Malviya had no experience when she started the job last year. Having just completed a diploma degree in nursing, she was hired after the Rajasthan government handed over management of the Ambirama PHC to the non-profit organisation WISH Foundation.

It was one of 41 PHCs that the state government allotted to private organisations early in 2016 in public private partnerships. Rajasthan said that this arrangement was necessary to overcome the staff shortages that had arisen at PHCs across the state because doctors and other medical personnel were unwilling to serve in rural areas, especially in the state’s desert and tribal regions. Private organisations running PHCs have been filling vacancies by hiring less experienced personnel like Malviya.

In addition to being relatively inexperienced, staff at these privately-run PHCs are often paid less than their counterparts in PHCs that are still run by the state government. As a consequence, staff attrition at privately manages PHCs is also high. This month, for instance, six PHCs run by Geetanjali Hospital and Medical College lost 11 employees and PHCs run by the Chitransh Education and Welfare Society lost 13.

“The staff at PHCs run on PPP keeps changing,” said Dr OP Bairwa, chief medical health officer at Pratapgarh. “So there is no continuity of medical services. People do not trust them much then.”

But despite such complaints by block and district level health officials, the state health department recently conducted a partial evaluation of the programme and declared it a success.

An Auxillary Nurse Midwife conducts a health check at a primary health centre in Rajasthan. Photo: Menaka Rao

The inexperience and rapid turnover of the staff at many of Rajasthan’s privately-run PHCs have diminished their efficiency. PHCs treat minor health problems and refer more serious illnesses to larger health facilities. But PHCs also play a crucial role in healthcare and promoting good health practices. For this, health workers need to develop trust in the communities they work with, which requires both experience and time.

For instance, said Dr Sanjeev Tank, chief medical officer of Udaipur district where six PHCs are run in public private partnerships, an auxiliary nurse and midwife with significant field experience is more effective in boosting preventive and promotive health services like immunisation programmes.

Little money

The gap between the wages of staff in privately run PHCs and government facilities can be significant. Malviya in Ambirama earns about Rs 10,000 a month, less than a third of what a lady health visitor employed by the government gets.

Kuldeep Joshi, a laboratory technician at the PHC at Achnera village in Pratapgarh run by Chitransh, earns Rs 6,000 a month – even as a government employee doing the same job would earn a little more than Rs 20,000. Ironically, Joshi had to take a salary cut last year. When WISH Foundation ran the PHC, he was paid Rs 10,000 a month.

At most privately-run PHCs, general nurses, pharmacists and lab technicians get paid only Rs 10,000 to Rs 12,000 per month.

Why do private operators pay their staff so little? The operators that the government does not give them enough money to increase salaries. The government pays private organisations between Rs 22 lakh and Rs 35 lakh per PHC per year, depending on how much the operator had bid to get the contract.

In a petition in the Rajasthan High Court, the health network Jan Swasthya Abhiyan asked that the public private partnership arrangement be discontinued. The petition pointed out that this amount is grossly insufficient to run a PHC and its sub-centres, so private operators compromise on delivery of healthcare and underpay their staff. The public private partnership agreements do not specify whether the salaries of staff hired by the private operators should adhere to government standards.

“The government is paying for staff [at the privately-run PHCs] at the fresher level,” said Dr RN Meena, the state’s joint director for hospital administration. “When we continue this for 5-10 years, these people will get promoted and earn more money.”

Anil Mathur who runs Chitransh said that the organisation cannot afford to pay employees at the same levels as government salaries. “Our employees are social workers,” he said. “We pay them honorarium, not salary.”

Kuldeep Joshi works as a laboratory technician in Achnera PHC. Photo: Menaka Rao

Underpaid medical personnel do not stay long at these privately-run PHCs.

Rajesh Singh, chief operating officer of WISH Foundation, said that the organisation’s PHCs have a staff shortage of about 40%. “We have been paying more salary to doctors in remote areas,” he said. “If we give them below par salaries, they will run away. We try to incentivise their stay by arranging for accommodation sometimes.”

He claimed that the organisation spends nearly 45% more money on running the PHCs than what the government gives them. The additional money comes from donors, he said.

Not all private providers can afford to pay higher salaries to their staff. “We try to manage with as much money as is given to us,” said Anil Mathur of Chitransh, which runs four PHCs in Banswara, Sirohi and Pratapgarh districts.

Tank said that private operators do not seem to have a plan to address the problem of high attrition. This leads to government health officials having to conduct repeatedly train new personnel.

“We train new recruits again and again but the staff [at privately-run PHCs] does not understand our government programmes well,” he added.

However, Omi Singh of Geetanjali Hospital which runs the six PHCs, denied that the government trains staff at these facilities.

In Karnataka, public private partnerships under the Arogya Bandhu scheme allowed non-governmental organisations to run PHCs. Like in Rajasthan, the private operators paid the staff much less than the government. An evaluation done by Indian Institute of Health Management Research in Bengaluru, found that this resulted in recruitment of less qualified staff. “It is very important to maintain the standardisation in the remuneration for the staff, because it is one of the motivational factors to work in the rural areas,” the institute said in its report.

Tough working conditions

Priyanka Lohar left her job as the lady health visitor at Savina PHC on the outskirts of Udaipur city when she got a contractual government job as an auxiliary nurse and midwife. “In the PPP mode, we do not even get travel or mobile expenses,” she said. “In the government job, at least that will be covered.”

Besides, personnel on government contracts may get permanent well-paying government jobs.

Staff in the PHCs under private management are allowed only one day off a week and do not get any other leave. If a doctor misses work for a day, the government cuts Rs 1,500 from the monthly payment to the private operator. The penalty for a paramedic missing a day of work is Rs 500.

Despite the low salary and poor working conditions Singh, who runs the PHCs for Geetanjali Hospital, believe that the PHC employees get a fair deal.

“Government doctor ke nakhre hote hai,” he said. “They throw tantrums. They take leave often. We do not have that problem.”

Anaemic pregnant women get their doses of iron-sucrose intravenously in Dalot PHC, Pratapgarh district. Photo: Menaka Rao

Dr T Sundararaman, dean of the School of Health Systems at Mumbai’s Tata Institute of Social Sciences, said the PHC partnership model works on the flawed expectation that the private player will run the PHC on lower costs and higher motivation. “But this motivation is only at the ownership level,” he said.

Unnecessary shortage?

Why is the government unable to get doctors and other staff to work in rural areas in the first place?

Dr Kishore Murthy, a healthcare researcher in Bengaluru, blames the bureaucratic and inefficient system of filling vacancies. “Some government officials feel the PPP model gives them the freedom to fill posts when necessary,” he said.

Sundararaman said the recruitment deficiency in the public health system has existed for a long time but there are simple ways to fix it. “The government should not wait for vacancies to fill posts and should in fact have a surplus of staff to account for employees quitting or going on leave,” he said.

Doctors are dissuaded from working in rural areas by the lower standard of living there, lack of education opportunities for their children and absence of technology, among other things, argued Dr Vikas Bajpai from the Centre for Social Medicine and Community Health, Jawaharlal Nehru University, Delhi. “All these aspects can only be taken care of by the government, not a non-governmental body,” he said.

The Indian Army Medical Corps is proof that the government can fix this problem, Bajpai added. “I am unable to understand how the government with its reach and logistics is not able to provide for doctors,” he said. “What qualities does an NGO have to provide care to people where the government has failed?”