SURVIVAL OF “PUBLIC PRIVATE PARTNERSHIP” IN QUESTION
An interesting Case-Study
Vanam Jwala Narasimha Rao, Consultant, HMRI
104 HIHL Services suffer from delayed Payments. It is only after Chief Minister N. Kiran Kumar Reddy in the presence of Principal Secretary Health Dr. P V Ramesh assured to sanction and release mutually agreed funds for operational expenditure as per MOU to HMRI that have fallen due for over three months, the concerned file for Additional Budgetary Release Order (BRO) moved from the Health Department to Finance. The proposal was in cold storage for more than three weeks and thanks to CM’s intervention and prompt action by Principal Secretary Health after that, the file was sent to Finance. Later, in just two working days, the Budget Release Order was issued from Finance and Administrative Sanction Order from Secretariat Health Department without any loss of time. Surprisingly, even after CM’s assurance, it took another three weeks, mainly due to the delay in the office of Commissioner of Health and Family Welfare (CHFW), for preparation of Cheque. It required 45Days and 104Step Process to obtain Government Funds, but not before CM’s intervention! Even with all this delay, CHFW did not clear all the dues though the Finance Department issued orders!
HMRI (Health Management and Research Institute) and CHFW (Commissioner Health and Family Welfare) , Government of AP entered in to MOU to operationalise two important Health care Delivery services benefiting the vulnerable sections of poor in PNPP (Public Not for Profit Private Partnership), namely 104-HIHL (Health Information Help Line) and FDHS (Fixed Date Health Services). The partnership started with 104-HIHL to begin with and extended later to FDHS.
The broad principle of sharing of costs is: “operational expenditure” to be born for both these services by the Government, where as HMRI on its part, in addition to management and research cost would provide technical knowhow and software besides developing various protocols. Consequent to resignation of the Founder Chairman of HMRI in January 2009, the Piramal Group had come forward to support HMRI and Sri Ajay G. Piramal has been invited to be the Chairman of HMRI since August 2010. Since then he is the Chairman of HMRI.
As against this background, since June 2010 the sanctions and releases to HMRI by the Government which are expected to be on the basis of “quarterly advances principle” as per MOU provisions were gradually diluted. Quarterly advances were replaced by monthly. Later, since July 2010, deviations in timely payments commenced and the monthly advances for operations were almost never adhered to. This resulted in late payments of not only salaries but also other operational and connected expenditure. Many a time, HMRI with its limited financial resources had to compensate and advance to avoid any breakdown in the Health Care Delivery.
Taking advantage of this late payment of salaries as well as uncertainty of sanctions of periodical increments to the staff (as provided in the MOU) some of the vocal members of the staff provoked others for resorting to strike the work in the HIHL call center. The strike was called off on the assurance of Principal Secretary Health to pay the increments.
While this was so, there were indications from various corners that the FDHS program was planned to be revamped and would be brought under the new scheme of Cluster Health and Nutrition Centers. This caused considerable anxiety, uncertainty and insecurity among the members of Field Staff. The happenings and the possible breakdown of the FDHS program as well as the resultant adverse affects on the vulnerable sections in the rural areas were brought to the notice of several important persons in the society-formally and informally during September-October 2010. The then Chief Minister, the Leader of the Opposition, TRS Leaders, the then Speaker of the Assembly, the then Minister in-charge of 104 Services as well as concerned senior officials in the Government were kept informed of the possible adverse affects of the proposed changes on the mind-set of FDHS staff. The staff concerns, in adequate budget provisions and delayed funds release were brought to the notice of Principal Secretary, Commissioner Health and Family Welfare from time to time.
104 Contract Employees Union affiliated to CITU went on strike from 10th November 2010. A Delegation from HMRI Management met the then Chief Minister Sri K Rosiah on 14th November 2010 and presented a memorandum regarding the demands of the striking HMRI Employees. Chief Minister assured the delegation that he would soon call for a meeting with all the authorities concerned to resolve the issues. HMRI Delegation explained in the memorandum that, the demands of the striking employees cannot be met by the management since all of them involve policy matters and financial support from Government. HMRI also indicated that demand to be favorably considered by government for resolving the issue and smooth functioning of peripheral services providing access to the unreached population of the state.
Ultimately the program was handed over to the District Collectors with effect from 4th December, 2010. Ever since this happened, the FDHS vehicles have seldom visited any village, in any district, on the fixed day as was done earlier. The sufferer is the voiceless poor patient!
The FDHS program that provided till then 2.73 lakhs Van days, visited 22,500 villages on an average 12 times and screened 116 lakhs people was handed over to Collectors from HMRI for no fault of the management. During the period the scheme was operationalized by HMRI more than 3.5 lakhs diabetic cases and seven lakhs hypertension cases were diagnosed and referred to the doctors, and drugs were issued each time they visited the service points. Nearly 13 lakhs pregnant women were registered and, on an average, all pregnant women were made minimum three compulsory visits. In addition, 20 lakhs children below 5 years, and 20 lakhs school children were provided services.
475 Mobile Health Units which provided once-a-month Fixed Date Health Service at every rural habitation located 3km beyond Primary Health Centers aimed at reducing maternal and child mortality and screen, identify and refer non-communicable diseases, are now lying idle in many districts for different reasons.
Since then, HMRI has been operationalizing only Health Information Help Line (HIHL) services. Since its inception it has received more than FIVE HUNDRED AND THIRTY LAKHS CALLS benefiting about TWO HUNDRED LAKHS VULNERABLE BENEFICIARIES. Recently it crossed an important milestone of providing more than FIVE LAKH beneficiaries with psychological counseling and averted around 800 potential suicides. AP HIHL which is the first of its kind in Asia is the world’s largest Health Information Help Line. On an average the Help Line receives daily around 39 thousands calls.
HMRI was not in receipt of funds on regular basis, as agreed to, since July 2010. Dues from the Government reached to a tune of Rs. 12. 39 Crores during 2010-2011 financial year. Against this background in response to a mail from HMRI, on 14th February 2011, Principal Secretary Health assured to work out a proposal for obtaining additional funds from Government.
A formal request in writing was also made to Commissioner Family Welfare (Signatory to MOU and responsible for sanctions and releases of funds to HMRI) in a letter dated 14th February, 2011 for sanction and release of Rs 12.39 Crores. Between CHFW and Secretariat Health Department’s Financial Advisor, the request was kept in cold storage until 7th March (Three weeks) and until the intervention of CM and Principal Secretary Health. Till then it was never seriously examined and was subjected to several queries made by Financial Advisor.
On 28th February, 2011 a mail was sent by Consultant to Chief Minister requesting for his intervention. There was a prompt response from CM office and an appointment was given to meet CM. Meanwhile mails requesting for intervention of Chief Secretary (on 3rd March, 2011) and Special Chief Secretary to CM (on 4th March. 2011) were also sent.
CEO HMRI along with Advisor and Consultants called on the Chief Minister on 5th March, 2011 (Saturday evening) and requested him for sanction and release of funds. This was preceded by an hour long meeting with Principal Secretary Health in the CM’s Camp Office. Chief Minister in the presence of Principal Secretary responded positively and assured to provide additional budget. He suggested to the Principal Secretary to ensure release of funds. HMRI management team subsequently met Special Chief Secretary to CM, Special Chief Secretary (Finance) and obtained assurance for budgetary provision as and when the request comes from Medical Department.
On 8th March, 2011 the proposal for additional Budgetary Release Order (BRO) was sent to Finance Department. The proposal after seen by three senior most officers (Secretary, Principal Secretary and Special CS) of Finance Department as well as routing through more than half a dozen steps, was approved on 11th March, 2011. BRO was issued and sent to HM&FW department same evening. It took just TWO DAYS in Finance Department. On return from Finance Department, Principal Secretary Health processed immediately and Administrative Order (GO) was issued same day and sent CFW department for further action.
As usual the further action and process was delayed by CFW until 16th initially and almost till 21st March later for obtaining DTA (Director Treasuries and Accounts) authorization. Meanwhile an interim payment of Rs. 2.00 Crores was made by CHFW pending clearance of LOC. Meanwhile to avoid any further delay, HMRI management team met Special CS Finance and Minister for Finance Anam Ramanarayana Reddy and requested for expediting. Secretary Finance approved and gave clearance for issue of LOC and after the formalities of stamping; LOC was issued by Pay and Accounts Officer and sent to CHFW on 24th March.
CHFW processed (but not before 28th March-another five days!) and the Cheque for Rs. 6.21 Crores has been signed by her sent to Secretary Finance IF for Counter Signature next day. Though the proposal was for Rs. 9.8 Crores, as against balance of Rs. 7.8 Crores to be paid to HMRI, an amount of Rs. 1.59 Crores is still awaited for payment! Neither the reasons were explained nor informed to HMRI management by CHFW. The Cheque is in hand on 30th March!
As against failure experiences of Public Sector Undertakings and Joint Ventures , in India, as in other countries evolved the concept of “Public Private Partnership” (preferably between Government and Not for Profit Private Institutions) and steadily gaining strength. Through Public-Private-Partnership (PPP), an otherwise government (Public) service is funded by state either totally or partly, and operated through a partnership between government and one or more non-governmental organizations or private sector companies (Private).
Non-profit organizations have special concern for reaching the poor and the disadvantaged, but, their sustenance depends on timely funding support from the government for operationalizing the scheme. Hence, the Public not for Profit Private Partnership survival is in question if this is the way the department (Health) concerned delays the sanctions and releases.
In spite of CM’s instructions and in spite of Principal Secretary Health orders, the Commissioner Family Welfare and her officers continued with the delay tactics in making payments. Though the Secretary Finance took just a day to clear the LOC, Commissioner Family Welfare proceeded with her delay tactics to issue the Cheque and took another five days! HMRI did not get the entire amount that has been due to them though Finance Department cleared, and CM as well as Finance Minister intervened!
While the Chief Minister responds to the request promptly and while the finance department right from the Minister down to the Secretary and concerned officers clears the proposals in a day or two, it takes weeks and months in departments (like Family Welfare) where proposals originate and are to be processed. If this happens for a normal and non-priority matters one can understand but when it happens to a not for profit health care delivery institution then the survival of PPP concept is in question. The very Health care Delivery is also in question.
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