India: Resolving Uttarakhand’s persistent challenges in health services

Providing health care to the scattered rural settlements in India’s Himalayan state of Uttarakhand has long been a formidable challenge.  Most mountain villages are difficult to reach and many of them are sparsely populated – more than 80 percent have less than 500 residents.  Landslides frequently block the roads, especially during the wet monsoon season, making it difficult for villagers to reach health facilities further away.

With limited infrastructure, shortage of medical equipment and large vacancies for doctors, footfalls in the state’s public health facilities have been low. People are often left with no choice but to travel long distances to reach larger hospitals in the plains. 

Now, for the first time, Uttarakhand’s rural settlements have access to a full range of health services thanks to public-private-partnerships (PPP) in three clusters of health facilities in the district centers of Ramnagar, Tehri Garhwal and Pauri Garhwal. Each cluster has a district hospital, two community health centers (CHC), and three mobile health vans, outfitted with the necessary medical equipment.

Since the model was implemented, more than 95 percent of specialists’ posts in the three district hospitals and CHCs have been filled. Whereas no surgeries were done earlier, more than 600 major surgeries and almost 1,500 minor ones have been carried out at these facilities over the past three years. 

“A lot of C-sections are now being performed,” said Dr Amit, the Chief Medical Superintendent of the district hospital at Tehri Garhwal. “Major surgeries are being done in orthopedics. General surgeries too. In fact, people are coming from faraway places to get treated here.”

At the Ramnagar district hospital we met Jyoti, a new mother from Dabri village some 30-40 km away.  Jyoti had just delivered a baby through C-section. “Earlier no such surgeries were possible here,” said the beaming young mother. “Now we no longer have to go to Dehradun (the state capital located in the plains) for a difficult pregnancy.”

Mahender Singh had travelled 60 kms with his pregnant wife to deliver their baby at the Ramnagar district hospital. “The hospital was clean, there was good care for the child, and vaccination was available,” said the pleased new father.

How it was done

Under the public-private partnership, the government has handed over all existing infrastructure at these facilities to the private partners in as-is condition. The private partner is responsible for providing quality services in accordance with specified norms. It is responsible for incentivizing, recruiting, and deploying doctors, lab technicians and paramedics at various facilities, equipping the facilities with diagnostic and medical equipment, as well as for ensuring that drugs, diagnostics, and consumables are readily available. The government, on the other hand, is responsible for paying the private partner on the achievement of mutually agreed key performance indicators. The initiative is supported by the World Bank’s Uttarakhand Health Systems Development Project.

Mahesh Prasad Uniyal, nursing supervisor at Boradi, Tehri, tells us that he now has 38 staff nurses and 7 in-charges. “I have staff nurses in 1:70 ratio. Emergency services are 24x7. With staff available here itself we do not refer patients to bigger facilities elsewhere.”

A key feature of the model is the detailed financial modelling that was conducted at the outset. This was a first of its kind in the country where the private partner was entrusted with a cluster of health facilities rather than just one facility.  This was supported by a baseline market assessment and a community engagement study to understand the gaps in access, availability, infrastructure, and the quality of services. 

In addition, the government’s health department appointed an Independent Monitoring and Verification Agency to verify whether the private partner has met the key performance indicators (KPI) before payments are made. These indicators cover critical areas such as the availability of staff, the quality of service provided, the satisfaction of patients, and the control of infections. If the provider exceeds the threshold for each indicator, a higher payment is given. If, on the other hand, the threshold is not met, the payment is reduced accordingly. 

Since this was the first of its kind transition, with all existing infrastructure being handed over from the public sector to a private partner, a detailed transition management plan was also developed to avoid disruption of services.

On the community side, patient committees were set up at each of the nine facilities in the three clusters. These committees meet quarterly to address patient grievances and determine corrective actions.

The early signs of transformation in health service delivery indicate that the model can effectively address some of the perennial challenges in providing health services in Uttarakhand’s difficult terrain.

The model can also provide a financially viable option for private operators to follow, while other states can adapt it to suit the own unique conditions.

With inputs from Rahul Pandey, Senior Operations Officer and Rajesh Jha, Senior Consultant (PPP)