PHFI’s reply gives hope, not confidence

The Public Health Foundation of India has responded to some probing questions, but many of the answers only reconfirm the lack of public scrutiny and accountability with regard to professionally-managed ‘public-private partnership’ entities. It's about time the government made all PPPs transparent and accountable

Over the past few days, Moneylife has challenged the functioning of the Public Health Foundation of India (PHFI), a little-know organisation that will play a powerful role in shaping India's healthcare policies and also framing the structure for training and education of healthcare professionals.

We showed how PHFI, with a powerful board (earlier headed by McKinsey's controversial Rajat Gupta and now by Infosys founder NR Narayana Murthy) comprising the biggest names in business (Mukesh Ambani is one of the members of the board) and government, is a low-profile and shadowy organisation that is not subject to statutory or public scrunity.

We carried at length the responses from Mr Murthy and the PHFI to our queries. Both only confirm that the potential of conflict of interest exist and there is a lack of clarity about who PHFI is accountable to. It is also very unclear why it should not be subject to the Right to Information Act, when it is clearly substantially funded by the government (in the form of land in various parts of the country and a few hundred crore rupees of direct investment).

Big questions remain about PHFI's defence of its legitimacy and authority. The reply to our query cites the "objectives" contained in the Memorandum of Association (MoA) filed under the Societies Registration Act, 1860. This MoA is not posted on the PHFI website, but it has a sweeping set of "objectives" posted under its "charter". They include:
* Assisting the growth of public health training departments.
* Establishing a strong national research network of public health and allied institutions.
* Establishing an independent accreditation body for degrees in public health which are awarded by training institutions across India.

PHFI's sweeping objectives read like the obligations of government and they are backed by government funds and empowered by the presence of India's senior-most bureaucrats on its board. Surely, an entity this powerful cannot function by merely filing an MoA with the Registrar of Societies without specific statutory backing? Remember, PHFI receives hundreds of crores of taxpayer money, free land and other support from central and state governments, not to mention membership/ invitation to vital government committees and public authorities?

PHFI has provided no answer.

About its claim that it is a "public-private partnership" (PPP), PHFI says "the Government of India decided on establishing the Foundation on a PPP mode" without answering the question as to why the PPP agreement, if any, is not in the public domain.

PHFI has nothing to say as to whether selection of the private partners was made on the basis of competitive bidding (or Swiss challenge or competitive negotiation, etc.) and in compliance with PPP rules. In fact it is clear that it is not.

PHFI has also nothing to say as to whether the "private partners" were acting as individuals or an organisation in entering the PPP agreement, who signed the PPP agreement, and what it contains.

In citing its "authority" to establish educational institutions as flowing from its MoA, PHFI is silent on the basis of its selection as a partner by state governments for setting up such institutions on a "PPP mode", as it claims, and whether competitive bidding was conducted in such selections and other PPP rules complied with?

(That gives rise to an interesting question. Since PHFI calls itself a 'public-private partnership', shouldn't its educational institutions in states be called 'public-private-public partnerships' or PPPPs?)

Courses and their approval

PHFI also fails to explain the basis of its selection by the Ministry of Health and Family Welfare (MoHFW) for imparting "public health training" when it is merely two years old, and the selection as trainer is akin to grant of a concession, and it also enjoys the privilege of receiving government-funded students. (The first public health school started conducting its programmes in July 2008, according to the PHFI website.)

There is also no explanation about whether the government follows any competitive process in granting privileges to PHFI, such as consultancy assignments and administering short-term training programmes to government employees.

PHFI strangely says its diploma programmes do not require a university affiliation, but has nothing to say on approval of such programmes by statutory regulators such as the Medical Council of India (MCI) and the All India Council for Technical Education (AICTE).

PHFI's reply confirms that it conducts no tests for admitting students or hiring faculty, but relies on what it calls "professional references" and "reference letters". {break}
Accountability and RTI compliance

PHFI says that its "governing council is accountable to its members". In other words, its governing body is not directly accountable to the Comptroller and Auditor General of India (CAG), statutory regulators, parliament and state legislatures, despite receiving public aid worth hundreds of crores of rupees.

PHFI's reply confirms that since its inception it has published no report on its finances and functioning for the scrutiny of the public and public bodies, and that it does not submit itself to a public audit.

While PHFI's performance reports and financial audits are "ratified" by the governing council, the Government of India is kept "informed", according to the reply. This is the basis on which a few hundred crore rupees and land is gifted to PHFI by the centre and state governments.

The claim made by PHFI in its reply that "the details of the constitution are available on PHFI website" flies in the face of facts; neither its memorandum of association nor the PPP agreement, if any, is posted on its website.

As for its RTI compliance, PHFI's reply leaves one puzzled.

It says, "PHFI abides by the legal framework of the (RTI) Act. It is not a public authority in terms of Section 3(h) of the Right to Information Act, 2005."

How can an organisation "abide by the legal framework of the RTI Act" without submitting itself to the Act as a public authority?

PHFI has no public information officer (PIO), does not respond to RTI applications, and its website gives nothing in terms of information required by Section 4(1)(b).

Section 3(h) cited in PHFI's reply is actually Section 2(h), which defines "public authority" and sounds tailor-made for PHFI.

Section 2(h) says: "Public authority" means any authority, or body, or institution of self-government established, or constituted by notification issued, or order made by the appropriate government, and includes any (i) body owned, controlled or substantially financed; (ii) non-government organisation substantially financed, directly or indirectly by funds provided by the appropriate government.

About conflicts of interests in its governing board, the PHFI reply merely cites its "principled stand" without saying why such conflicts should continue.

Where is 'public' in public policy?

The PHFI story has an echo in the ongoing debate triggered by Anna Hazare's Jan Lokpal movement over whether the unelected should get to influence public policy.

The question is who should get to influence public policy? Those who get a place in government committees by working hard to win wide public support for decidedly public causes, such as fighting corruption? Or those who just sneak into government committees on the strength of their wealth and connections, want their money to be counted as their competence, avoid public scrutiny and accountability, and straitjacket public policy into serving their class interests?

Why should 'public-private partnership' be defined only as giving corporate interests a say in formulating public policy and not creating platforms for the larger cross-section of society to contribute to laying down public policy?

The PHFI case holds a lesson for the citizens: PPPs in their present form are a fraud on India's democracy.

Any organisation that refuses to submit itself to the RTI Act and other institutions of public accountability does not deserve a rupee of taxpayers' money, let alone thousands of crores of public funds that are currently being placed under private control in the name of PPPs. The government's stubborn refusal to bring all PPPs under the RTI Act needs to be challenged and opposed in the law courts and on the streets.

Until that happens, the Montek Singh Ahluwalias do not deserve a sound sleep.

This is the fourth and concluding part of a series on the functioning of PHFI. You may want to read the previous three parts:

Will PHFI be any different under Narayana Murthy

Will PHFI become transparent and accountable under Narayana Murthy?

Mr Narayana Murthy, PHFI reply to questions about the authority and functioning of the organization

(Kapil Bajaj is a freelance journalist and blogger based in Delhi. He has worked for Press Trust of India, Business Today, and other organisations. His interests are democracy and public policy.)

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    Atul Patankar

    8 years ago

    As usual, you have taken a subject still neglected by every one else. And cover it in detail, after a lot of research and home work.

    People’s health campaigners urge Maharashtra to adopt TN model for medicines procurement

    Jan Swasthya Abhiyan and Jan Arogya Abhiyan say state requires transparent, professional body like the Tamil Nadu Medical Services Corporation which is demand-responsive and not supply-based

    The Maharashtra government's decision to introduce the e-tender system to procure medicines for state public health institutions has been appreciated by some public interest groups. But they feel it is inadequate and that the state government should adopt the 'Tamil Nadu model' that has been successful over the past one and a half decade.

    Jan Swasthya Abhiyan and Jan Arogya Abhiyan, both working towards better and more affordable health care for disadvantaged people, have in an online petition to chief minister Prithviraj Chavan and health minister Suresh Shetty, said that in Tamil Nadu, all indoor and outdoor patients in government health facilities get medicines free and as a result about 40% of patients in the state seek care at these centres.

    However, after five years of the National Rural Health Mission (NRHM) in Maharashtra, the supply of medicines to people in the state has not been even one-third that of Tamil Nadu.

    The per capita government expenditure on medicines in Tamil Nadu is Rs29 as compared with Rs20 in Maharashtra, they have pointed out.

    Last week, the Maharashtra state cabinet approved the e-tendering system for procurement of medicines, putting an end to the decade-old rate-contract system. The government has explained that aside from curbing corruption, the new system would help to get better quality medicines and at a cheaper rate.

    Previously, purchasing medicines for state-run institutions was the responsibility of the Directorate of Medical Education and Research. The state buys about Rs300 crore worth of medicines annually, Rs75 crore of this for hospitals attached to medical colleges.

    In Tamil Nadu, the state government set up the Tamil Nadu Medical Services Corporation (TNMSC) in 1994 as the sole purchaser and distributor of drugs to government medical institutions, with the aim of reducing the cost and ensuring regular supply of quality drugs to health facilities.

    The items available from the TNMSC are listed in a booklet which contains an essential drugs list, based on the guidelines of the World Health Organisation, and is available with doctors, nurses and pharmacists, as well as post-graduate institutions.

    These items are available from a warehouse designated for each district. In addition, doctors have an emergency fund to purchase other drugs. The institution is given a passbook which details the funds it is allowed to spend on medicines and surgical items, based on the previous year's outpatient and inpatient attendance and the number of surgeries performed. Additional supplies or additional funds can be requested from the TNMSC.

    Kamayani Bali Mahabal and Ram Adsule, convenors of Jan Swasthya Abhiyan, and Dr Anant Phadke, convenor of Jan Aarogya Abhiyan believe that the success of the system in Tamil Nadu has not been merely due to e-tendering, but also other factors like the complete professional autonomy to the TNMSC which maintains transparency in procurement and distribution.

    They said that the e-tendering adopted in Maharashtra is proposed to be done by a set of officials from various departments who will not be able to give enough time and justice to this work which requires professional devotion. The committee which will select the medicines to be procured will include five or six private practitioners, two each from renowned private hospitals and from the Maharashtra Medical Council, and two experts. They have questioned why so many private sector doctors are on the committee, but no renowned civil society health groups with any conflict of interest are represented in this committee.

    The letter further explains that the distribution system in Tamil Nadu is demand-responsive. For example, each primary health centre (PHC) can choose the medicines and the quantity according to their need within the budget of Rs1 lakh by using the passbook in which entries are made as medicines are lifted from the stock. However, in Maharashtra the PHCs are supplied medicines irrespective of their needs. This leads to unused stocks of some medicines in some PHCs and shortage at other PHCs.

    What is probably worse, according to a new system of distribution being planned, private contractors would supply medicines from regional warehouses to PHCs. But this privatisation experiment would likely fail, or run into problems and result in chronic shortage of medicines at PHCs and rural hospitals.

    The health activists wondered why Maharashtra was seeking to experiment with a new system when the Tamil Nadu model was working successfully also in Kerala and is being adopted also in Rajasthan and Bihar. They said that half-baked, ill-conceived experiments would only be harmful and that the system of procurement and distribution of medicines in Maharashtra required nothing less than a complete overhaul.

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    Narendra Doshi

    8 years ago

    Since the Model has successfully run for so long in some States it is high time that this - the health of an individual who is an Indian- must be taken care by the Indian Central Government & not left for further so called new partial experiments & thereby go backwards by a few decades & also losing individual economical well being.

    Of cabbages and kings … and Kalmadi

    Our education system is totally geared to producing sterile graduates who are fit for nothing productive... Yet, befuddled parents are spending more and more on education of their children

    Mark Twain, whose real name was Samuel Langhorne Clemens, wrote: "Education isn't everything. A cauliflower is only a cabbage with a college degree."

    Taking the other tack, education in India is nothing. All the deluded cabbages go to college and come out as mere cabbages with college degrees. Very few transmogrify into cauliflowers and most of these cauliflowers go to the US, or the IITs and the IIMs, from where they go on to jobs abroad at princely salaries-and sometimes get caught in insider trading cases. They probably form less than one quarter of one-per cent of the population.

    What happens to the cabbages that remain cabbages but with college degrees? They have stepped on to a walkway of a life of frustration, helplessness and shattered hopes and false ambitions which were pumped into them by society, their parents and, as Alexander Pope, the satirical English poet, put it, "what nurse and priest have taught".

    In theory, a college education is supposed to get the student a job. But, what chance has a simple BA or BSc of landing a job even as a lower division clerk in a tahsildar's office. So the pitiable little ones languish. Parents force girls to get married. I know of a case of a girl who passed MBBS but was pressurised to get married; she was even prevented from working as a doctor after marriage.

    The point of all this is that our education system is totally geared to producing sterile graduates who are fit for nothing productive (except making children). Even those who go on to do third-rate diploma courses in fourth-rate computer or management academies (which have proliferated like rabbits) cannot find jobs.

    For instance, experts say that 70% of the young people who apply for jobs in industry are unemployable. The Economist magazine has also reported that a same percentage of applicants in the IT sector are unemployable.

    Yet, befuddled parents are spending more and more on education of their children.

    A survey by the National Sample Survey Organisation (NSSO) states that between 1999 and 2009, expenditure on food increased by about 70% among rural families and 78% among urban ones. But the spending on education jumped up by as much as 378% in rural areas and 344% in urban areas. Even after correcting for inflation, the expenditure on education increased by a phenomenal 162% in rural areas and 148% in urban areas during the period.
    What a waste of hard-earned money. We have to change our system of education so that it creates productive citizens who can get jobs and are happy that they are earning something to support their families.

    There are hundreds of studies by experienced and thinking people suggesting a big shift towards a productive education system. One of them is to teach tenth standard and Plus-2 students a skill which makes them attractive to employers, like handling a lathe, a CNC machine, repairing cars and two-wheelers, tailoring, plumbing, carpentry, electrical work, the list is endless. Two years of such study and we will have millions of happy and productively employed young people.

    PARTING KICK: Now to something not really connected to this subject, but not really unconnected either. Mark Twain's aphorism implies that intelligence and quick thinking are more than sufficient to get along in life. Take the example of Suresh Kalmadi who is intelligent enough to claim that he has dementia and frequent loss of memory and hence is not mentally fit to be tried in the Commonwealth Games case.

    I can visualise a scene in which a panel of neurologists, psychiatrists, psychologists and lawyers is quizzing Kalmadi on his claims.

    Question: What is your name?
    : Suresh Kalmadi.

    Question: So you remember your name. No loss of memory here?
    No sir, but there are a lot of things that I don't remember.

    Question: And what are the things that you don't remember?
    Sir, I don't remember that I was the head of the Commonwealth Games Organising Committee. I don't remember that I and others siphoned away thousands of crores from the funds allotted for the Games. I don't remember that I am now imprisoned in Tihar Jail.

    (R Vijayaraghavan has been a professional journalist for more than four decades, specialising in finance, business and politics. He conceived and helped to launch Business Line, the financial daily of The Hindu group. He can be contacted at [email protected].)

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    Narendra Doshi

    8 years ago

    Very well said. We need to very seriously impart such education which creates productive citizens who can then get jobs, as rightly said. This was true in my school days and is more true now in my senior citizen days.

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