2. STRUCTURE
• WHAT IS IT AND IS IT HAPPENING?
• WHAT ARE THE TRENDS?
• WHAT IS THE PICTURE IN HEALTHCARE IN INDIA?
• TRANSFORMATIVE (RE)MUNICIAPLISATION?
3. WHAT IS IT AND IS IT HAPPENING?
• DESPITE CONTEXT, UNNOTICED COUNTER WAVE OF EXPANSION OF PUBLICLY PROVIDED SERVICES TO MEET
CURRENT CHALLENGES, INCLUDING THROUGH BRINGING SERVICES BACK INTO PUBLIC HANDS (DE-
PRIVATISATION).
I) RE-NATIONALISATION: SERVICES BROUGHT BACK UNDER GOV CONTROL AT NATIONAL LEVEL
II) NATIONALISATION: CREATION OF NEW SERVICES OR BRINGING SERVICES UNDER NATIONAL
CONTROL
III) RE-MUNICIPALISATION: SERVICES BROUGHT BACK UNDER REGIONAL OR LOCAL AUTHORITIES
IV) MUNICIPALISATION: CREATION OF NEW SERVICES OR BRINGING SERVICES UNDER REGIONAL OR
LOCAL GOV CONTROL
• 2019 SURVEY: 1,408 (RE)MUNICIPALISATION CASES INVOLVING MORE THAN 2,400 CITIES IN 58 COUNTRIES
• 63 CASES OF DE-PRIVATISATION IN HEALTHCARE: NOT EXHAUSTIVE OR SYSTEMATIC
• ECONOMIC CONTEXT: SURGE DURING GLOBAL FINANCIAL CRISIS
4.
5. WHAT ARE THE TRENDS? (1)
1. PROCESS LED BY LOCAL AUTHORITIES:
• MAIN ACTORS ARE THE LOCAL / REGIONAL GOVERNMENTS (DEVOLUTION OF POWERS)
• REGIONAL VARIATIONS: LATIN AMERICA (RE)NATIONALISATION, EUROPE (LED BY MUNICIPALITIES), IN ASIA
STATE / REGIONAL AUTHORITIES (INDIA, MALAYSIA) AND MAYORS/CITY (SOUTH KOREA AND PHILIPPINES)
• AUTHORITIES ARE NOT WAITING FOR CHANGE AT NATIONAL LEVEL.
2. (RE) MUNICIPALISATION REDUCES COSTS AND IMPROVES SERVICES
• 245 CASES AIMED TO OR RESULTED IN REDUCE THE COST OF PROVIDING SERVICES.
• 264 CASES, MUNICIPAL COMPANIES FORESEE OR INCREASED INVESTMENT IN IMPROVING SERVICES AND
INFRASTRUCTURE
• 188 CASES REMUNICIAPLISATION STRIVED FOR ENSURING LOWER FEES.
• THIS IS IMPORTANT EVIDENCE AGAINST THE NARRATIVE THAT PRIVATE SECTOR SAVES COSTS.
3. PRIVATISATION DEALS ARE OFTEN ECONOMICALLY UNVIABLE
• 26 CASES OF BANKRUPTCIES OF PRIVATE OPERATORS
• 73 CASES PRIVATE OPERATOR WITHDRAWAL
• 586 CASES (63%) THE CONTRACT EXPIRED AND WAS NOT RENEWED.
• MARKET FAILURE PLAYS A KEY ROLE
6. WHAT ARE THE TRENDS? (2)
4. INTEREST TO PROMOTE PROGRESSIVE CHANGE
• UN SPECIAL RAPPORTEUR ON EXTREME POVERTY (2019): PRIVATISATION FURTHER MARGINALISES PEOPLE
LIVING IN POVERTY AND IMPACTS ON THEIR ECONOMIC AND SOCIAL RIGHTS
• 138 CASES: POLICY OBJECTIVE OF DEFENDING SOCIAL AND HUMAN RIGHTS
• PROGRESSIVE POLICY SHIFTS CENTRAL TO PROCESS IN GERMANY – RENEWABLE-ENERGIES LED SYSTEMS
5. WORKING CONDITIONS
• PRIVATE OPERATORS: JOB CUTS, ERODING WORKING CONDITIONS, UNDERMINING COLLECTIVE BARGAINING,
PRECARIOUS WORK.
• 158 CASES IMPROVED WORKING CONDITIONS
• QUESTION OF ABSORPTION OF PRIVATE SECTOR WORKERS
6. DEMOCRATIC PUBLIC OWNERSHIP:
• PUBLIC SERVICE RESPONSIVENESS
• 149 CASES FOR IMPROVED DEMOCRATIC CONTROL IN PUBLIC OWNERSHIP (ACCOUNTABILITY,
TRANSPARENCY MECHANISMS, PARTICIPATORY GOVERNANCE
• 76 CASES PUP (PUBLIC-PUBLIC PARTNERSHIPS), BETWEEN USERS, WORKERS OR THE COMMUNITY AND LOCAL
AUTHORITIES.
7. WHAT IS THE PICTURE IN
HEALTHCARE IN INDIA?
• MORE CASES THAN EXPECTED, UNDER STUDIED
• ACROSS HEALTH CARE SEGMENTS
• PATTERNS OF PRIVATISATION
I) OUTRIGHT SELL
II) OUTSOURCING OF SERVICES OR FUNCTIONS
III) PRIVATE FINANCING (FOR INSTANCE BOOT)
IV) PASSIVE PRIVATISATION
8. • PRIVATISATION PATTERN: RARELY OUTRIGHT SELL, PRIVATE FINANCING TENDS TO FAIL BEFORE
COMPLETION (RGSSH, TAHRIPUR). MOSTLY PASSIVE AND OUTSOURCING TO THE PRIVATE
THROUGH MANAGEMENT CONTRACTS (PPPS).
• RAJIV GANDHI SUPER SPECIALITY HOSPITAL IN RAICHUR, KARNATAKA
• DHFW BUILT WITH OPEC SUPPORT. GIVEN TO APOLLO (AHEL), MANAGEMENT CONTRACT IN 2001
(INCLUDING FINANCING)
• 2007: FACT FINDING DOCUMENTED DENIAL OF CARE TO BPL PATIENTS, HARASSMENT AND OUTRIGHT
FRAUD. WORKING CONDITIONS STARTED DETERIORATING (EXHAUSTION OF GRANT).
• 2011: DHFW ASSESSMENT (CONTRACT TO EXPIRE IN JUNE 2011). CONCLUDED THAT AHEL HAD BEEN
UNSUCCESSFUL IN EFFICIENTLY RUNNING THE HOSPITAL, ADEQUATELY SERVE BPL POPULATION, NOT
BROKEN EVEN.
• CONTRACT ENDED (EITHER NOT RENEWED OR TERMINATED) AND HOSPITAL WAS SHUT ON 1 JUNE
2012.
• EMPLOYEES AND COMMUNITY OPPOSED HANDING OVER TO PRIVATE ENTITY (RIMS), DEMANDED
REOPENING OF THE HOSPITAL AS AN AUTONOMOUS BODY OR RUN BY STATE GOVERNMENT.
• 2013: REOPENED IN NOVEMBER UNDER DEPARTMENT OF MEDICAL EDUCATION.
WHAT IS THE PICTURE IN
HEALTHCARE IN INDIA?: HOSPITALS
9. WHAT IS THE PICTURE IN HEALTHCARE IN
INDIA?: PRIMARY CARE
• PHC PRIVATISATION: PRINCIPALLY THROUGH OUTSOURCING (PPPS). MIGHT INCLUDE
FACILITY UP GRADATION. E.G. KARUNA TRUST MANAGES 80 PHCS IN 7 STATES.
• POPULATION OUTREACH PRIVATISATION: OUTSOURCING. UNFOLDING.
• MOBILE MEDICAL UNITS IN CHHATTISGARH
• 2012: EXPANSION OF MMUS THROUGH PPP AS A RESPONSE TO OPERATIONALIZATION
BOTTLENECKS.
• FLEET OF 30 MOBILE MEDICAL UNITS ROLLED OUT, PHASED MANNER, BOTH RURAL AND
URBAN.
• PPP TERMS: GOV PROVIDED OPERATING COSTS, PART OF DRUGS AND SUPPLIES, NO CAPITAL
EXPENDITURE.
• 2013: AFTER LESS THAN A YEAR, PRIVATE ENTITY HALTED SERVICES
• 2014: GOCH TERMINATED THE CONTRACT DUE TO THEIR POOR PERFORMANCE, NON-
PAYMENT OF SALARIES, TOOK OVER OPERATIONS.
• GOVERNMENT MMU ARE RUN AT 1.6 OF THE OUTSOURCED MMUS. BETTER ABLE TO PROVIDE
SERVICES TO THE MORE REMOTE AREAS. PROPER ASSESSMENT REQUIRED
10. WHAT IS THE PICTURE IN HEALTHCARE IN
INDIA?: HEALTH RELATED SERVICES
• PRIVATISATION PATTERN: PIECES OF HEALTH RELATED SERVICES ARE OUTSOURCED FROM
DIAGNOSTIC SERVICES, TO MEDICAL SERVICES AND INTERVENTIONS (DIALYSIS SERVICES,
CATARACT OPERATION), AND AUXILIARY SERVICES (SUCH AS HOUSEKEEPING, DIET, SECURITY,
WASTE COLLECTION).
• ECONOMIES OF SCALE: PROVIDING SERVICES TO SEVERAL HOSPITALS CREATES ADVANTAGES.
• TN MUNICIPAL SERVICES CORPORATION NETWORKED SYSTEM FOR DIAGNOSTICS
• SINCE 1994, TNMSC DOES POOLED PURCHASE OF DRUGS AND DEVICES FOR GOV FACILITIES IN TN
THUS TNMSC OWNS RADIOLOGY EQUIPMENT (IMAGING MACHINES AND CENTRES).
• 2019: NETWORKED 58 CT SCAN DEVICES AND 18 MRI MACHINES IN GOV HOSPITALS IN THE STATE.
RADIOLOGISTS FROM ANY OF THE HOSPITALS CAN ACCESS AND GIVE MEDICAL OPINION
• LOGIC OF ECONOMIES OF SCALE TAPPED BY CREATING NETWORKS UNDER PUBLIC AUTHORITIES WITH
PUBLIC INTEREST ETHICS, IN ORDER TO STRENGTHEN CAPACITY OF PUBLIC HEALTH SYSTEM
• BUILDS ON EXISTING RESOURCES, RESPONDS TO LACK OF STAFF, INFRASTRUCTURE, THROUGH
POOLING.
11. TRANSFORMATIVE (RE)MUNICIAPLISATION?
• THERE ARE CASES OF (RE) MUNICIPALISATION IN HEALTHCARE IN INDIA, WHICH
ARE NOT DOCUMENTED SYSTEMATICALLY
• ACTUALLY, NOT EVEN MUCH INTEREST FROM THE PROGRESSIVE HEALTH
COMMUNITY.
• IN CONSEQUENCE, CASES ARE MOSTLY PASSIVE (RE)MUNICIPALISATION /
PRAGMATIC (RE)MUNICIPALISATION.
• ACTIVE (RE)MUNICIPALISATION OPENS OPPORTUNITIES FOR TRANSFORMATIVE
(RE)MUNICIPALISATION, THAT CHANGES REALITY ON THE GROUND, AS WELL AS
CHALLENGES THE DOMINANT NARRATIVE.
• ILLUSTRATE THROUGH THE JAKARTA WATER (RE)MUNICIPALISATION STRUGGLE
12. TRANSFORMATIVE (RE)MUNICIAPLISATION?
JAKARTA WATER
• 1991: UNION GOV: JV WITH UK’S THAMES WATER AND FRENCH SUEZ FOR WATER DISTRIBUTION IN JAKARTA CITY
• 1998: FAILED CITY GOV ATTEMPT TO DE-PRIVATISE. LED TO CREATION OF KRUHA, PEOPLE’S COALITION FOR THE
RIGHT TO WATER
• KRUHA CAMPAIGN INCLUDING PUBLIC EDUCATION, SEMINARS, OUTREACH ACTIVITIES, PROTESTS, RALLIES, POLICY
ADVOCACY, AND LITIGATION.
• 2004: 13 ORG’S CASE AGAINST THE WATER RESOURCES LAW: COUNTER TO THE RIGHT TO WATER – LOST.
• 2011: NEW POLITICAL CONTEXT. NEW COALITION CREATED. CAMPAIGN RESTARTED, DISCOURSE BRINGS IN WATER
JUSTICE – ALLOWS TO QUESTION THE SYSTEM THROUGH WHICH WATER IS PROVIDED.
• 2012: CASE AGAINST THE UNION GOVERNMENT FOR THE BREACH OF THE RIGHT TO WATER.
• 2015: DISTRICT COURT ANNULLED THE CONCESSION, BASED ON A CONSTITUTIONAL COURT ORDER THAT ANNULLED
WATER RESOURCES LAW.
• CAMPAIGN FOR (RE)MUNICIPALISAITON SHIFTED THE DISCOURSE IN A SIGNIFICANT WAY, TO WHY IS PUBLICLY
PROVIDED WATER NECESSARY TO ENSURE THE RIGHT TO WATER, WITH JUSTICE.
• IMPLEMENTATION UNDERWAY (RENEGOTIATION OF THE CONTRACTS)
• TRANSFORMATIVE POTENTIAL IN THE LIVED REALITY, AS WELL AS IN THE DISCOURSE.
14. WHAT IS THE PICTURE IN HEALTHCARE
IN INDIA?: HOSPITALS (2)
• FORTIS ESCORTS HEART CENTRE IN RAIPUR, CHHATTISGARH
• BUILT BY GOV. HANDED OVER TO ESCORTS (LATER FORTIS) FOR MANAGEMENT IN
2002.
• 2017, GOV OF CHHATTISGARH DECIDED NOT TO EXTEND THE AGREEMENT.
HOSPITAL CLOSED DOWN, SERVICES PROVIDED AT ADVANCE CARDIAC INSTITUTE AT
DR BHIMRAO AMBEDKAR MEMORIAL MEDICAL COLLEGE, RAIPUR
15. WHAT IS THE PICTURE IN HEALTHCARE IN
INDIA?: POPULATION OUTREACH SERVICES
• PRIVATISATION: OUTSOURCING. UNFOLDING.
• MOBILE MEDICAL UNITS IN CHHATTISGARH
• 2012: EXPANSION OF MMUS THROUGH PPP AS A RESPONSE TO OPERATIONALIZATION
BOTTLENECKS.
• FLEET OF 30 MOBILE MEDICAL UNITS ROLLED OUT, PHASED MANNER, BOTH RURAL AND
URBAN.
• PPP TERMS: GOV PROVIDED OPERATING COSTS, PART OF DRUGS AND SUPPLIES, NO
CAPITAL EXPENDITURE.
• 2013: AFTER LESS THAN A YEAR, PRIVATE ENTITY HALTED SERVICES
• 2014: GOCH TERMINATED THE CONTRACT DUE TO THEIR POOR PERFORMANCE, NON-
PAYMENT OF SALARIES, TOOK OVER OPERATIONS.
• GOVERNMENT MMU ARE RUN AT 1.6 OF THE OUTSOURCED MMUS. BETTER ABLE TO
PROVIDE SERVICES TO THE MORE REMOTE AREAS. PROPER ASSESSMENT REQUIRED
16. WHAT IS THE PICTURE IN HEALTHCARE IN
INDIA?: PRIMARY CARE CENTERS
• PRIVATISATION: PRINCIPALLY THROUGH OUTSOURCING (PPPS). MIGHT INCLUDE
FACILITY UP GRADATION.
• KARUNA TRUST PRIMARY HEALTH CENTERS IN KARNATAKA
• KARUNA TRUST MANAGES 80 PHCS IN 7 STATES. STARTED FROM KARNATAKA
• PILOT IN AT GUMBALLI PRIMARY HEALTH CENTRE BASE FOR GOK 2000 PPP POLICY,
OUTSOURCING OF ALL PHCS IN THE STATE, MOST TO KARUNA TRUST. PPP INCLUDES
FUNDS GENERATION BY PRIVATE PARTY.
• COMPLAINTS OF NON-COMPLIANCE OF RULES, MISUSE OF FUNDS, LACK OF
ACCOUNTABILITY AND FAILURE TO PROVIDE QUALITY SERVICE TO PATIENTS
• 2016 GOK REVOKED ALL PPP PHCS, INCLUDING WITH KARUNA TRUST. 52 PHCS BACK
UNDER GOV CONTROL.
