People’s Health Movement-North America spoke with activists from Jan Swasthya Abhiyan (JSA or PHM-India) in the state of Chhattisgarh who shared their experience of organizing a successful campaign against the state’s plan to outsource labs and diagnostic services to private providers. Chandrakant, who lives in one of the many villages of Chhattisgarh, is a health activist and part of JSA. Sulakshana Nandi also lives in Chhattisgarh and serves as a national co-convener for JSA. Neelanjana Das, also a member of JSA, joined us to provide translation.


The background

Formed in 2000, Chhattisgarh is a relatively new state in India. Being located in a part of the country that has always been neglected socially and economically, Chhattisgarh struggles to provide quality, accessible public services to its residents. When the state was founded, the government devoted considerable resources to strengthening public services, including the public health system, but continues to struggle to provide adequate health services for its people.

The National Rural Health Mission (NRHM) The Indian government created the National Rural Health Mission was created in 2005. It brought more investments into the public health system, especially in places like Chhattisgarh. By 2012-2013 the public system had improved, but there were still problems, such as with recruiting human resources.

In addition to being a new state, many residents of Chhattisgarh are Adivasi (indigenous people) who rely heavily on the public health system. Also many parts of the state are hilly or densely forested, making it difficult for health professionals to reach people in these areas. And, in general, the government has neglected the public health system–not ensuring the availability of medicines and supplies or human resources–which exacerbates already existing challenges.

In an attempt to address the deterioration of the public health system, the government of Chhattisgarh decided to engage in public-private partnerships (PPPs). It announced this decision in December of 2012 in a new policy: “Strengthening health services in Chhattisgarh state through Public Private Partnerships”. As part of this policy, the government planned to outsource several public health services to private companies and issued Request for Proposals requesting bids from private companies to operate these services. While many of the Request for Proposals failed, the one for the outsourcing of labs and diagnostic services in public facilities moved forward.

The Request for Proposals identified 379 public labs that would be privatized. However, many of these labs were already providing the diagnostic services the plan targeted. This signaled that the government had decided to abandon the existing public labs rather than continuing programs to scale up and strengthen them.

Instead of actually dealing with the issues that were there in terms of centering of the public health system this was, according to [government leaders], the way out in terms of outsourcing the diagnostics.Sulakshana Nandi

In response the new policy and Request for Proposals, JSA of Chhattisgarh organized a statewide campaign over the next six months to keep the labs public. The campaign was organized from the ground up by people who lived in remote villages and in urban areas, and some of the most marginalized groups of people joined the actions. They were able to mobilize the masses, with hundreds of thousands of people participating in demonstrations across the state and with support from across the country.

The campaign lasted from about January 2013 to August 2013. Throughout this time, the government did not respond to the campaign’s demands or the public’s disapproval of the policy and its plan to privatize these labs. However, after several months of sustained public pressure, the government pulled the plan to privatize these 379 labs.

How did they do it?

When JSA learned of the government’s proposal they first worked to simply understand what was happening and what the impact would be on people’s daily lives. This first step was the most important in order to lay a foundation for evidence-based critiques of the proposal and to educate the community on how the policy would impact their lives. It was also necessary for building an effective strategy against the plan and organizing a coalition around this strategy.

RESEARCH

The proposal itself gave activists no insight into why the government was making this decision; it gave no information on why it had selected certain labs to outsource and leave others alone. Activists had to find out this information on their own.

JSA relied heavily on the Right to Information Act to gain clarity about what the government was planning. They filed a request under the Act to find out what kind of services were already being provided by the public health system. The state’s response revealed that it had not done any study or surveys prior to issuing the Request for Proposals. JSA organizers would have to evaluate the situation on the ground themselves. They would use this as an opportunity to ascertain the public’s opinion of the policy.

The campaign used “rapid surveys” to collect data. Activists contacted as many of the labs listed to be outsourced as possible by phone or in person. Focusing on the 50 lab tests that were being targeted, they asked primary health centers which of the services they did and did not offer. The rapid surveys showed that many of the tests flagged to be outsourced were already being offered in existing facilities. JSA concluded that the government had done no analysis of the current state of the labs and services they offered. 

The campaign also used experiences from other parts of India, including districts in Chhattisgarh, to support its critique of the proposal. Experience had shown that private companies were more likely to locate services in urban, more populated areas where larger profits are guaranteed. They did not ensure that services would be available in rural or more remote areas of the country.

Based on their research, JSA developed a point-by-point critique of the new policy and the Request for Proposals to outsource labs and diagnostic services. JSA found that having such a strong critique gave legitimacy to their campaign and its demands. It caught the attention of the media and served to mobilize local communities and organizations who later became part of the campaign.

The research continued throughout the campaign and as the situation changed. When the government began to publish companies’ responses to the Request for Proposals, the campaign collected and analyzed those. The responses confirmed the campaign’s critique, showing that, indeed, the companies were more concerned about their own profits than the people’s health. 

We had said as per previous experiences and the evidence…in other areas of the country and within the state…that the private sector would not want to go to the more remote areas or the rural areas. And this kind of privatization is always pushed giving the rationale that “government doctors don’t go to rural/remote areas so that’s why we’re privatizing”. When finally the private agencies responded to the advertisement, they refused to go to the remote districts. So it was sort of a self-fulfilling prophecy and supported the campaign.Sulakshana Nandi

BUILDING COALITION

JSA has had a presence in Chhattisgarh for many years. Its broad network of health activists–individuals and organizations–was key in facilitating outreach and mobilization. It was also crucial that the membership of JSA is diverse. Members and organizers are from not only urban centers but also from rural areas and remote villages. 

JSA and its partners first engaged in local outreach. They did outreach in larger cities as well as small villages and remote parts of the state. They organized local meetings to spread the word about the government’s plan for privatization. They also worked to engage new people and organizations to build support for a statewide campaign.

After this period of local outreach, there was enough interest and momentum to hold a statewide meeting. In January of 2013 the first statewide meeting brought together a range of civil society organizations and individuals. This meeting served as a campaign launch and a strategizing session.

Organizers who spoke the local languages of villages and remote areas were able to translate the information the campaign produced, so it was accessible to everyone they approached. When members of JSA went back to their villages after the state meeting they were able to raise awareness about the issue, stressing that health is a human right and that this policy would threaten that right.

They already had experiences where they had seen that privatization actually didn’t help them. There were only negatives they experienced from privatization.Chandrakant

MASS MOBILIZATION

This whole onslaught of neoliberalism had been felt by the people of Chhattisgarh much before this campaign, this struggle, started. It was also a rallying point that bought so many different organizations together. They understood: my land, which I was doing agriculture on, has now been given to industry for mining, and I am displaced. Similarly, these health facilities are a public good, it’s our resource…a public resource. So, if it is given to a private company, what could be the implications of that?Sulakshana Nandi

 
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Recalling previous experiences of privatization

There is a history in Chhattisgarh of the people protesting and organizing against the sale of their land and natural resources to private companies. Many groups who joined the campaign had been involved in this previous organizing and were able to build on past experiences to illustrate the harm of the government’s privatization of health services. They were able to connect the two issues in a very concrete way for people to understand: Their public health system was being sold away just as their land and forests had been.

Reaching rural and remote areas

It was key for the campaign to have presence in some of the most remote villages. Many of the individuals who were involved in the campaign lived in these places, and organizations who joined the campaign already worked there. It was important to ensure that people living in these areas, who might not be able to travel to district offices or the capital, were able to express their disapproval of the policy.  They worked to share their disapproval of this privatization scheme to the government through sending postcards, writing to the government officials, and holding sit-ins at the block level.

Connecting health workers and the community

Sulakshana and Chandrakant explained that there is often conflict between health workers and the community due to lack of services, but the campaign brought together health workers and community workers in solidarity against the government’s PPP policy.

Working together in the campaign, health workers were better able to understand the lives of the people and the struggles in the communities where they work. At the same time, community members came to understand challenges that health workers face. They realized that this was a problem of the system and not individual choices. This understanding allowed them to become united, and this unity strengthened the movement overall.

Networking beyond health

The networking done with organizations working on issues other than health contributed to the rapid and broad growth of the campaign. These organizations included NGOs, people’s organizations, and lab tech and health worker unions. Through this networking, organizations came to understand how privatizing these health services would harm the people with whom they work, and they expanded their work to include this message. Through outreach to these organizations, people whom the campaign may not have otherwise reached became motivated to support and become active in the campaign as it grew.

AMPLIFYING THEIR VOICES

Public actions

The campaign organized very large, public actions which drew more attention and more supporters. Chandrakant observed that, while the government remained unresponsive, it was sustained public actions such as these that contributed greatly to the campaign’s success.

Rally: In January 2013, the  JSA and its supporters organized a march through the state capitol to launch the campaign. The march ended with a rally where organizers gave speeches decrying the PPP proposal and the government’s plan for the labs. Campaign representatives handed a critique of the proposal for outsourcing and a list of demands to a government representative who was present. Some members of JSA also held a press conference during the rally.

Sit-ins: The campaign organized sit-ins across the state’s 27 districts. People gathered at the block level and at district headquarters, making a point to be highly visible. As the sit-ins continued, groups working against privatization in other sectors took notice as to how pervasive privatization is. They mobilized to support and join these actions, which strengthened the campaign overall

Signature campaign: The campaign collected signatures from across the state, including villages, to hold the government accountable, to raise awareness about the issue, and to demonstrate to the government the people’s disapproval. The signature campaign was a strategy that had been used in a previous right to food and right to work campaign, and people remembered participating in that.

Silent march: One of the largest actions of the campaign was a silent march in the capital in May 2013. Hundreds of people, from many different groups—including from marginalized and vulnerable communities—came together for this silent march. Protestors tied a black cloth over their mouths to mark their silent protest. They also carried large sheets with thousands of signatures of people who opposed the new policy. This action was especially significant because it concretely showed the level of disapproval of the privatization plan from people across all parts of society.

Media

The media found the campaign important to cover given the history of mining in the state and the impact of privatization on people’s lives. Local organizers would alert the media when they planned demonstrations at the block level. JSA sent regular press releases to local and statewide media outlets; national media also took interest in the campaign. Some newspapers published series on the campaign and checked in periodically as the situation changed. The media covered the impacts of the PPP proposal on hospitals and used language helpful to the campaign with headlines such as, “The Government is Selling Hospitals”.

The unique strategies the campaign used caught the attention of the media at the local and district level. And although the media covered these actions, organizers still thought more needed to be done in order to sway the government. The silent march in the capitol was organized to be very large and a completely different type of demonstration than usual. The visuals sent a message of the gravity of the situation. It was after the silent march that media coverage began to spread rapidly.

Support from outside of the campaign

Many supporters of the campaign, from across the country, had reputations of supporting public health programs and pushing for a strong public health system. The fact that these individuals expressed their support of the campaign and its demands gave the campaign more credibility and caught the attention of some government officials.

JSA groups from other parts of the country follow the campaign and spread information it circulated in their own local media. They also shared this information through their own interactions with government officials or other influential people. They supported the campaign in suggesting strategies and contributing research and other information which aided in building and maintaining momentum for the campaign.

There was a particular atmosphere that was created due to this campaign, and media built a story around that and helped the movement.Chandrakant

 
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Reflecting…

THE SUCCESS OF THE CAMPAIGN

When asked what they would consider the pressure point that lead the government to rescind the PPP plan for labs and diagnostic services, Sulakshana and Chandrakant recalled that many people who held leadership positions in the government—at the district and state level—actually agreed with the analysis and demands of the campaign. Further, the state government had requested money from the national government and the National Rural Health Mission (NRHM) to fund the proposal. They speculate that evidence the campaign submitted led to the national government declining to fund the proposal.

IMPACT OF THE CAMPAIGN

There has been some strengthening of the existing public lab facilities, with some trainings and recruitment of lab technicians. Procurement of supplies has been further streamlined. However, these actions have been insufficient, giving the impression that the government is not interested in investing in the public health system to strengthen it overall. The government must still improve the labs in public health facilities, and the campaign continues to monitor this.

The government has again made a similar proposal (as of our conversation in October 2018), issuing a call for proposals for private companies to take over labs. JSA has critiqued the proposal and is once again sending petitions to the government in opposition of it.

ORGANIZING SINCE THE CAMPAIGN

During the campaign old relationships were renewed and many new relationships were formed. Particularly, for JSA, the participation of the health works union, with which JSA had not had previous interaction, was a starting point in becoming more closely associated with unions and health workers themselves. JSA continues to organize around the issues health workers raised during the campaign, fortifying their work around health worker rights.

THE POWER OF THE PEOPLE

The struggle united an incredible amount of people from all over the state–from different geographic areas and different social groups. When the government pulled the PPP plan, the people felt they’d gotten the message across that privatization is no help to them–it is a burden. The campaign wanted to send a resounding message to the government that their concern was not this single, present issue but also about the future. Now, after the success of this campaign, the people believe in their power and stand ready to organize against privatization as the issue rises again.

The real victory was in the fact that all of these people came together from various organizations united in the struggle. And they were able to oppose this entire privatization movement that the government was trying to shove down their throats. These people came together and realized the power that they have when they are united. That was the true victory. They realized that they could actually make change. —Chandrakant

 

Resources

Sulakshana Nandi: Struggle Against Outsourcing of Diagnostic Services in Government Facilities: Strategies and Lessons From a Campaign Led by Jan Swasthya Abhiyan (People’s Health Movement) in Chhattisgarh, India 

Sulakshana Nandi: Struggle Against Outsourcing of Diagnostics in Chhattisgarh

Chhattisgarh is outsourcing diagnostic services to the private sector despite having adequate staff

Meera Kay: Chhattisgarh’s proposal to outsource diagnostic services draws criticism

People’s Health Movement–India