Outsourcing of diagnostic services in public health facilities in Chhattisgarh. A critique by Jan Swasthya Abhiyan Chhattisgarh
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1 Outsourcing of diagnostic services in public health facilities in Chhattisgarh A critique by Jan Swasthya Abhiyan Chhattisgarh The Chhattisgarh State Government has taken out a Request For Proposal (RFP) for outsourcing of diagnostic services in public health facilities 1. This note first enumerates the various features of the RFP and goes on to analyse its implications, and experience of a similar initiative in Bihar. What does the Advertisement say? 1. Outsourcing of radiology and lab services in 379 facilities: Three levels of Diagnostic Center have been identified- Category A consists of the 100 bedded District Hospitals. Category B consists of newly created District Hospitals, FRU Community Health Centers and Civil Hospitals Category C consists of non- FRU CHCs and 24*7 Primary Health Centers Type of Facility Number of facilities Category- A Category- B Category- C facilities to be outsourced facilities in the state District Hospitals Civil Hospitals CHCs 46 (FRU) 103 (Non FRU) PHC (24*7) The initial RFP divided the state into four Divisions- Bastar, Raipur, Bilaspur and Sarguja. However, there were no applications for Bastar and Sarguja. The lost were then redefined and the four divisions were combined into two- Sarguja along with Bilaspur and Bastar along with Raipur Services to be provided: The services include radiology and laboratory services. Three categories of services have been described. The services under each category are detailed in Appendix 1. Upto 25% of category- C centres may be allowed to function as collection centres. NABL accreditation not compulsary mentoflots.pdf
2 3. Eligibility and operating procedures: Private profit or not- for profit Eligibility as per experience and turnover NABL accreditation should be done within 2 years and that too only for Units in A and B Can appoint own staff or can further contract it out to a concessionaire Agency or Concessionaire both have to comply with standards under Nursing Home Act. Each to be maintained as a business centre 4. Project period: Agreement for 10 years with annual renewal 5. Concessions given by Government: RKS will provide space and electric meter. Freedom to serve external customers Will get right to first refusal in expanding this network to medical colleges and other facilities not included here. 6. Rates and Expected volumes: Rates will be those approved for non- NABL accredited centre in Delhi under CGHS. Excerpt from Table on expected volumes is in Apppendix Payment Mechanism The payments will be made by the Jeevan Deep Samiti for the following patients: Patients being treated under RSBY Patients being treated under Mukhyamanti Swasthya Bima Yojana (MSBY) BPL patients under OPD treatment Rest of the patients will pay for the services themselves. 8. Monitoring: Monitoring by third party monitoring system Will mutually set performance levels If higher performance, then bonus of 5% If lower performance, State will write to improve performance, if not done then penalty of 5% Critique 1. Bulk Coverage: This proposal is attempting to outsource diagnostic services in bulk of the hospitals in the state. Most of these hospitals already have a functioning lab. The
3 proposal covers most of the non- remote areas too where provision of lab facilities is anyway not difficult. The proposal covers- ALL Community Health Centers (CHCs) in the state; 80 % of the District Hospitals (22 out of 27 District Hospitals); 8 out of 17 Civil Hospitals; and 200 of the best functioning Primary Health Centers (PHCs) in the state 2. Replacing existing diagnostics services: It is evident that this is not seen as an interim arrangement (the Agreement being for ten years), rather as completely replacing the services being provided by the facilities. It completely ignores the fact that the necessary diagnostics services are currently available in most of these facilities. What will happen to the existing HR and the lab set-up/equipments in the facility? The list of hospitals and tests listed does not seem to be based on any analysis of lab services already available in the public health facilities. The RFP has also been revised to allow collection centers in 25% of Category C centers. Experience of this in Bihar has been very negative. From the first round of bidding it is evident that the private parties are unwilling to go to Bastar or Sarguja as they don t find it profitable. Now that the government has combined two divisions together the private parties might demand more money for the Bastar and Sarguja. Therefore, instead of improving and expanding the services already being provided by the various facilities, this initiative will completely destroy the existing services and replace them with privately and more expensively provided services and collection centers. 3. Lack of Match between Lab Services proposed and availability of Specialists/Doctors: The basic range of diagnostic services to be provided at each level has to be matched with the availability of doctors and specialists. In this proposal there seems to be no such match. In Category A facilities, i.e. older District Hospitals, there are some specialists available and most tests corresponding to their specialization are also already available. Therefore there seems no logic of outsourcing the services in them. For example, District Hospital Korba or Mahasamund. In Category B facilities, mainly the FRU CHCs and new District Hospitals, there are hardly any specialists in CHC and most tests that are necessary are being done. For example, in Manendragarh CHC, all tests in the list are currently being done. In District Hospital Dantewada, all the tests (other than stool tests) are being done. Therefore, outsourcing of diagnostic services in these facilities means that these functioning labs will be rendered redundant after outsourcing.
4 In Category C, in the PHCs there are no MBBS doctors in Chhattisgarh. As per order of the state government, MBBS are pooled in CHCs and Rural Medical Assistants (with 3 year diploma) run the PHCs. The question is without a MBBS being posted in the PHC, how will an X- ray be useful? Thus there seems to hardly any rationale in outsourcing lab facilities at any level in Chhattisgarh today. 4. Delayed NABL accreditation and no mention of AERB guidelines: The proposal provides flexibility to the units to get NABL accreditation after 2 years. This is of concern as it is not clear till then what would be the quality checks and balances. Additionally, the RFP completely ignores the AERB (Atomic Energy Regulation Board) guidelines, something that is currently a matter of great concern in Bihar. 5. Entitlements of patients not stated: The proposal does not state the entitlements of patients and neither does it clarify whether the services will be free of cost. Duties of the unit towards patient have not be laid down, nor mentioned. There is no charter of rights of patients and neither is there any mention of any kind of grievance redressal system. The Government has mentioned that RSBY and the new insurance scheme (Mukhyamantri Swasthya Bima Yojana) will ensure higher number of patients for the units and their expenses will be paid under RSBY and MSBY. But this scheme covers only in-patients. Also, experience till date of irrational medical practice in RSBY in Chhattisgarh and other states has shown that this too will be reflected in diagnostics. With regards to out- patients, the RFP states that Jeevan Deep Samitis will pay for BPL patients while the rest of the patients have to pay for their investigations. Now, the Government of India identifies only lakh households as BPL in Chhattisgarh, while, according to the Chhattisgarh Food Security Act 2012, 42 lakh families (75% of families in the state) have been identified as poor and needing food support. Therefore the irony is that 23 lakh poor households of those who are covered under CGFSA, will be made to pay for diagnostics services. The question arises, that if these families have been identified as deserving support for food, how can they not be deserving of free healthcare? Furthermore, what about all those tests under National Disease Control Programmes like malaria, sickle cell, TB and those under Mother and Child Health Programme? How will the private centers be made to provide tests that are already free under various Government programmes? Will an APL patient with fever have to pay for malaria tests or will an APL pregnant woman have to pay for anemia test?
5 6. Concession of serving external patients: The RFP states that the agency will be able to serve external patients in addition to IPD/OPD patients in the hospital. This might lead to mixing of patients where hospital patients might end up paying and external patients may be shown as internal. 7. Monitoring systems: The RFP talks of a 3 rd party monitoring mechanism. This means that the government will not be monitoring and instead a 3 rd party will do so. The selection of the 3 rd party again would then be through a bidding process. It is difficult to be certain that the external 3 rd party will do fair monitoring. Instead it means that rather than dealing just with a set of one s own staff, the health department will have to deal with two private agencies; one running the units and another one monitoring them. There is no mention here of grievance redressal systems and monitoring by the community and PRIs is completely ignored. Only financial penalties are mentioned in the RFP in case of low performance and as the performance parameters are not set, this whole aspect is currently in the dark. 8. Experiences in other states ignored: There does not seem to have been any analysis or reflection of initiatives taken by other states to strengthen their public health facilities nor of the experience of outsourcing of diagnostics elsewhere. Tamil Nadu offers an example in contrast where, without any outsourcing the public health facilities, even the PHCs have been able to provide well functioning diagnostic services. Outsourcing of diagnostic services has been tried out in few states, Bihar being the largest model. The 6 th Common Review Mission 3 clearly states that this has been a complete failure. The absolute failure of the outsourcing of diagnostics in Bihar is something which the government should have taken note of before launching on this initiative. The 6 th Common review Mission of NRHM states: As mentioned earlier, laboratory services are delivered through PPP model which is not functioning properly. At most of the places below district hospital level, outsourced agency has set up only collection centres. This leads to prolonged turn- around time and reporting time. The services were contracted out to provide those diagnostic tests, which are not conducted at the facilities lab. However, now PPP labs are conducting same tests, which are done by the in- house lab. This has led to under utilization and even dysfunction of in- house labs, leaving the govt. lab technicians without their professional work and is being sub- optimally (6 th CRM, Bihar 2012: 14). The report further goes on to say: 3 Report of the 6 th Common Review Mission- Bihar, 2012
6 Diagnostic Services - The state has outsourced diagnostic services under PPP, as per following details Status of functional Radiology & Pathology Centres in the state under PPP mode (PHCs to DHs) Ultrasound 40 X- Ray 303 Pathological Lab 34 Pathological Sample Collection Centre 252 However, instead of strengthening of Public Health System, outsourcing has resulted into closure of hospital laboratory and X-ray facilities at almost every facility. Thus, the regular staff (laboratory technician, x-ray technician/ radiographer) has become redundant. Following are few of the other problems, which are cause of concern and the state may look into a) Personnel managing x- ray machines and laboratory services are not qualified as per prescribed norms. As a result accuracy and reliability of test results is doubtful. b) Personal safety is not being adhered to. E. g. Usage of TLD badges and lead aprons. c) X- ray machines are non- compliant to AERB norms. d) Site approval for Radiology Departments are not available e) Kidney function tests and liver function tests are paid services at the visited facilities for all categories of beneficiaries. f) Long turn around time (6 th CRM, Bihar 2012:15) The 6 th CRM therefore recommends that in Bihar: The hospital should operationalise its own laboratories, which are practically non- functional now because of existing arrangement for diagnostic services under the PPP mode. Out- sourced services should supplement the existing structure and public services, not become its substitute (6 th CRM, Bihar 2012: 72-73). The question then arises is that if this has been tried before and has been a failure, then why try to do a similar thing in Chhattisgarh? The Bihar experience clearly shows that in outsourcing these services, the existing staff and set up in government hospitals have become redundant. The scale of the current proposal is huge and the RFP document clearly states that there is possibility of extending this to medical colleges and other facilities not currently in this RFP.
7 Appendix 1
8 Appendix 2 Part of the Table on expected number of cases: Division Category Number of Facilities Average daily OPD % OPD cases expected to require (per facility) CT Scan USG X- ray Lab Tests A Sarguja B C A Bastar B C A Raipur B C A Bilaspur B C
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