Special Thematic Section on " Rethinking Health and Social Justice Activism in Changing Times " 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

Since 1991, India, like many countries, has undergone a process of ‘liberalisation’ which has entailed an increase in outsourcing of public services through Public Private Partnerships. In December 2012, Chhattisgarh state started the process of outsourcing diagnostics and radiology services in 379 government health facilities. Jan Swasthya Abhiyan (People’s Health Movement) Chhattisgarh mounted a (so far) successful campaign against this move. Drawing on secondary data and the personal experiences and observations of the author, this paper documents Jan Swasthya Abhiyan’s struggle, describing the strategies that were used, their efficacy, the facilitators and challenges. It uses this experience as a basis to reflectively suggest lessons for health activism and the theoretical implications. Jan Swasthya Abhiyan founded its resistance on a detailed evidence-based critique of the proposal that was disseminated, along with demands. The campaign then usedmultiple strategies, from petitioning the government, to street action, to advocacy with media and bureaucrats. Alliances were built with trade unions and groups working on social justice issues. Privatisation and neo-liberal policies provided a rallying point and framing the issue as a moral argument and in terms of larger concerns for social justice helped build wider solidarity. This experience suggests that the use of evidence and multiple strategies, effective framing of the issue, forging broader alliances, and a sustained campaign can all be important strategies for health activism. It also highlights the need for health activism to continue beyond a single campaign. Staying vigilant, monitoring, evidence building, mobilizing people and continuing to build alliances on such issues are critical tasks for social movements and networks like the People’s Health Movement.


Background
As part of a global process of 'liberalisation' over the last three decades, there has been continual pressure to privatise public services globally and in India.These reforms were driven by the World Bank and the IMF that Journal of Social and Political Psychology jspp.psychopen.eu| 2195-3325 supported commercialisation, privatisation and competition (Birn, Pillay, & Holtz, 2009).Globalisation and Structural Adjustment Programme (SAPs) led to a retreat of the state from many sectors, with sectors like health bearing the brunt (Baum, 2001).After 1991, in order to adhere to IMF structural adjustment loan conditions, India was forced to cut down public expenditure.As a result, government health expenditure went from 1.4 per cent of GDP in the mid-eighties to 0.9 per cent in 2002 (Rao, 2009).The public health scenario that emerged at the time was grim.Government hospitals had to impose user fees, most states were unable to hire health staff, free drugs and diagnostics were no longer being provided, and more beds could not be added in government hospitals (Public Health Resource Network [PHRN], 2013).A decline in routine immunisation coverage as shown in 2002 government figures illustrates the grave consequences of the resource shortages in general health services at the time (Priya, 2005).While starving the public sector of funds, the government promoted the growth of the private sector.However, during this period, the growth of the private sector was skewed towards urban areas and supply driven services (Public Health Resource Network [PHRN], 2013).Surveys of the time show that the expenditure on treatment was the second most common cause for rural indebtedness among the poor (Banerji, 2001).This thrust on greater privatisation has not only been seen in health services, but in all public services like education, electricity, roads and infrastructure, both in India and globally (Birn et al., 2009;Labonté & Schrecker, 2009).Women and vulnerable groups often faced the brunt of such 'reforms' (Shiva, 2013).
By the early 2000s, the disastrous impact of the Structural Adjustment Programmes (SAPs) was clearly visible (Birn et al., 2009).The new Indian coalition government (United Progressive Alliance) which came into power in 2004 attempted to reverse these trends, the National Rural Health Mission being one of the universal programmes introduced at the time.However, though the Indian Government increased its health budget, its thrust on the growth of the private sector remained.It increased subsidies to the private sector and engaged in Private Public Partnerships and outsourcing of public services, catering more to international demands rather than local needs (Rao, 2009).Navarro (2000), in his assessment of the 2000 World Health Report asserts that the World Health Organisation (WHO) too seemed to have decided that publicly funded and provided healthcare systems are outdated.He criticises the WHO for propagating market-demand based, rather than need based planning (Navarro, 2000).The understanding was that governments should not 'provide' or 'make' health services, but instead 'purchase' or 'buy'.Such an understanding sees healthcare as a commodity, rather than as a public good or a social good and patients as clients.The claims made by the World Bank and others in favour of privatisation of health services have been that the private sector market would make for more efficient, effective and equitable management of health services and despite evidence that this strategy has led to decreased healthcare access, especially for the marginalised, World Bank and others have continued to promote it (Birn et al., 2009;Marriott, 2009).In more recent years, under the paradigm of "Universal Health Coverage' (UHC), private sector involvement in providing publicly funded healthcare is being promoted and expanded (Sengupta, 2013).The People's Health Movement (PHM) is a global network of civil society organisations, grassroots health activists, and academic institutions, mainly from low and middle income countries (LMICs).PHM strives towards achieving health equity and health for all, with a strong focus on the social, structural and political determinants and people's participation.PHM has been a strong critic of the impact of neo-liberal policies and SAPs and believes that for people's health to improve, governments, and not markets, need to intervene, and that public health governance needs to improve along with active participation and advocacy from people's movements and public health professionals (Baum, 2001).
Jan Swasthya Abhiyan (JSA) is the India circle of PHM.JSA has a national coordination committee that consists of other networks, organisations, individuals and state representatives.Each state has its own JSA chapter, facilitated by conveners.This paper describes the campaign by Jan Swasthya Abhiyan (JSA) Chhattisgarh against the proposal for outsourcing of diagnostic services in government facilities.It aims to describe the strategies that were used, the efficacy of those strategies, the facilitators and challenges in the struggle and on the basis of that experience, to suggest lessons for health activism in current times.

Outsourcing of Government Health Services in India
A direct impact of the above policies has been the increase in outsourcing of public services, including for healthcare, under the umbrella of 'Public Private Partnerships' (PPPs).PPPs are varied, ranging from outsourcing of primary health services, to global PPPs (Kapilashrami, 2010).The National Rural Health Mission (subsequently re-named as National Health Mission) talks about Public Private Partnerships as supplementing government services (Jan Swasthya Abhiyan, 2006;National Health Systems Resource Centre, 2012).The recent National Health Policy of 2017 makes a case for private sector involvement and talks about government engaging in 'strategic purchasing' of health services (Ministry of Health and Family Welfare, 2017).
In India, like in many other LMICs, low budgetary allocations and inadequacies in government health services, along with the expectation that 'purchasing' from a private provider will be more 'efficient' and also bring in private investment, are often used as the rationale for engaging in PPPs (Roy, 2017).However, in India, it mainly translates into outsourcing certain public health services or facilities to the private sector that are expected to provide these services using government funds and/or user fees (Baru & Nundy, 2008).The other rationale given for engaging in PPPs is that of 'reaching the unreached', i.e. reaching the 'underserved' areas, which are mainly the remote, rural, tribal areas of the country (Ministry of Health and Family Welfare, 2017).There is however increasing evidence of failure of outsourcing health services.Though many attribute this to the failure of governmental regulation, the failure of such projects are mainly a result of the inherent nature of public services to be provided (Kotecha, 2017), the incongruence between market logic and social logic (Leys, 2018) and the inability of the market to play a social role (Deppe, 2009).In India, recent studies led by the author show that though certain PPPs may have led to an increase in or provision of health services in the short run, it often fails to strengthen the overall health system and may end up exacerbating existing problems (Public Health Resource Network [PHRN], JSA, & Oxfam, 2017a, 2017b, 2017c, 2017d).

Introduction to Chhattisgarh State
Chhattisgarh is a new state, formed in 2000 (Government of Chhattisgarh, n.d.).It has a population of about 25 million of which 77% live in rural areas (Office of the Registrar General & Census Commissioner, India, 2011).It is seen as a 'tribal' state with 32% of the population belonging to tribal or indigenous communities, with the districts situated at the northern and southern parts of the state having highest tribal populations (Office of the Registrar General & Census Commissioner, India, 2011).These 'tribal' districts are hilly and forested while the central plains have more urban centers with mainly non-tribal population (Government of Chhattisgarh, n.d.).
As a new state, Chhattisgarh started many new reforms focused on strengthening the government health system, starting from the primary healthcare levels, including initiatives like the Mitanin Community Health Worker programme (Sundararaman, 2007) and a three year medical course to prepare health workers for rural and remote areas (Rao et al., 2013).The National Rural Health Mission that was launched in 2005, supported these reforms for government health system strengthening.However, the state continued to face challenges in providing health services in the rural and remote areas, some of the reasons being the historical neglect of the area leading to lack of higher educational institutions and therefore lack of qualified human resource, and issues in implementation and governance.
In 2012, through the initiative of a technical assistance agency and certain bureaucrats in the health department, a state policy on 'Strengthening health services in Chhattisgarh state through Public Private Partnerships' was developed and notified by the government (Department of Health and Family Welfare, 2012).This was followed by a number of Request for Proposals (RFPs) for such partnerships that were advertised, which included proposals for outsourcing of Mobile Medical Units, Primary Health Centers, Referral transport, school health programme and so on.The proposal for outsourcing of diagnostic services that is discussed in this paper, was part of this group of outsourcing initiatives.Most of these proposals either got stalled at the bidding stage or had to be shut down after some time (Public Health Resource Network [PHRN] et al., 2017b;Times News Network, 2014).
This paper aims to describe the struggle by JSA Chhattisgarh against Chhattisgarh government's proposal for outsourcing diagnostic services in government facilities.The paper will present strategies that were used and their efficacy, the facilitators and challenges in the struggle and finally, the lessons for health activism in current times.

Methods
This paper draws on secondary data and the personal experiences and observations of the author, who, being the Convener for JSA in Chhattisgarh, herself was involved in the struggle.The secondary sources of information include the notes, critiques, petitions, memorandums and emails circulated during the campaign.It also draws from the official documents related to the outsourcing, media articles and subsequent studies on PPPs.In analysing the implications of this campaign for health activism in current times, the author has subsequently also drawn on theories of social movements and social activism.
As a participant in the struggle, the author was involved in planning the campaign and developing the resource materials.The author's potential biases as a researcher-activist may have affected the analysis, and therefore rigour has been attempted through reflexivity (Malterud, 2001).The positionality of the author regarding the context and what is to be investigated and the motivation for undertaking this research have been made explicit.Being part of the struggle has helped the author in bringing out unique evidence and practical insights.Methodologically, this study hopes to contribute to the literature on solidarity research and work with respect to social movements (Brem-Wilson, 2014;Mishler & Steinitz, 2001).
In what follows, the nature and strategies of the anti-privatisation campaign are first presented, following which I reflect on lessons learned with potential applicability to other contemporary social movements.

The Proposal, the Critique and the Campaign The Proposal for Outsourcing Diagnostic Services in Government Facilities
The Request for Proposal (RFP) was advertised in December 2012 (Directorate of Health Services Chhattisgarh, 2012).It was put up on the health department's website and bids were elicited from companies and organisations.
The RFP was amended in January 2013 after incorporating concerns of the private agencies at the pre-bid meeting (Directorate of Health Services Chhattisgarh, 2013a).The amended RFP also included certain points emerging out of JSA's critique, for instance, the revised RFP had more details on who will pay for the services.
The salient features of the proposal are given in Table 1.The facilities were categorized into three levels (A, B, C), according to their level of functioning and requirement.The list was to be subsequently expanded to include medical colleges and other facilities.
The initial RFP divided the state into four Divisions or lots-Bastar, Raipur, Bilaspur and Sarguja.However, in the first round of bids, organisations applied only for the two divisions situated in the central, non-tribal, relatively more urban

Geographical coverage
belt (Bilaspur and Raipur) and there were no applications for the tribal and remote regions of the state (Bastar and Sarguja).The government then re-defined the lots and combine one tribal region with a non-tribal region (Sarguja along with Bilaspur and Bastar along with Raipur), thereby forcing the bidder to take up the tribal areas if they wanted to bid for the non-tribal divisions (Directorate of Health Services Chhattisgarh, 2013b).
The services to be provided included radiology and laboratory services.Three lists of tests were prepared, according to level of facility.Upto 25% of the lower facilities were allowed to function as 'collection centres'.

Services to be provided
Agreement for 10 years with annual renewal Project period Both private profit and not-for profit organisations could apply, with defined minimum experience and annual turnover.
Accreditation under the National Accreditation Board for Testing and Calibration Laboratories was not necessary, and Eligibility and operating procedures could be done within 2 years and that too only for higher facilities.They were free to appoint own staff or could further contract it out to a 'concessionaire'.The agency or Concessionaire had to comply with standards under the state's Clinical Establishment Act.Each center was to be maintained as a 'business centre'.Concessions given by Government included space and electricity.They would have the 'freedom' to serve 'external' customers.
The payments were to be done per procedure or tests on the basis of government rates.For patients being treated under the state funded health insurance scheme for hospitalisation and for Below Poverty Line patients undergoing ambulatory

Rates and payment mechanisms
or out-patient care, the payment would be made by the Hospital Management Committees.The rest of the patients were to pay for the services themselves, out of pocket.
Monitoring was to be done by a third party and performance based incentives were designed.Monitoring Source: Prepared by the author on the basis of the revised RFP document (Directorate of Health Services Chhattisgarh, 2013a).

Campaign by JSA Chhattisgarh Against the Outsourcing Analyzing and Critiquing the Proposal
The JSA Chhattisgarh members got to know about this move of the government very soon after the RFP was put up on the website.They accessed the RFP as it was in the public domain and started to analyse it.It became clear to them that this move of the government had the potential to harm and undermine the existing public services and therefore JSA activists developed its critique.The critique argued out some of the common assumptions and rationale for such a move, and also tried to show the impact that this move will have on the existing diagnostic services in these facilities (Jan Swasthya Abhiyan Chhattisgarh, 2013).The critique was substantiated by evidence from within and outside the state.Some of the main points were as follows: Questioning the rationale that the outsourcing was meant for -This proposal was attempting to outsource diagnostic services in bulk of the hospitals in the state.This included even the non-remote areas, where lab services could be provided within the government system as human resource and accessibility were not a problem.Moreover, it was suspect whether the private agencies would be willing to go to remote areas as they won't find it 'profitable' enough.This suspicion came true when in the first round of bidding, no one applied for the 'tribal' and remote divisions (Directorate of Health Services Chhattisgarh, 2013b; Pandey, 2015b).Subsequently when the government combined two divisions (one remote and one non-remote) together, there was the danger that the private agencies could demand extra incentives and funds to go to the remote districts, thereby increasing the costs for government.
Questioning the evidence on which this proposal was based -A reading of the proposal showed that it had ignored the fact that certain diagnostics services were currently available in most of these facilities.The hospitals and tests seemed to be listed en bloc and not based on any situational analysis or study (Jan Swasthya Abhiyan Chhattisgarh, 2013).There was the question of what would happen to the existing human resource (HR) and the lab set-up and equipment in the facilities once outsourcing was complete.Moreover, the RFP had also been revised to allow collection centers in 25% of the less functioning centers and it was feared that this would hinder timely access to services.The government's own evaluation of diagnostics outsourcing in states like Bihar had found that it had led to redundancy of existing human resource, the in-house facilities had become dysfunctional and the services that were previously being provided were stopped (Ministry of Health and Family Welfare, 2012).
Moreover, the evaluation also found that having collection centres had led to delayed turn-around time Concerns regarding replacing existing diagnostics services -It was evident from the proposal that the existing services were not being improved or expanded, rather the existing diagnostics services would practically be replaced by services being provided by private agencies, something that had already proven disastrous for the government health services in Bihar.

Concerns regarding cost to patient and their entitlements -
The proposal mentioned that the state funded health insurance scheme would cover costs of patients, but that meant that costs only in the case of hospitalisations were to be covered and not ambulatory care.Moreover, instances of unethical healthcare and provider-induced demand had been documented under this scheme within the state and outside and there was the danger of this happening in the case of diagnostics too (Mazumdar, 2013).
With regards to ambulatory or out-patient care, the proposal mentioned that the hospital management committees would pay for the BPL (Below Poverty Line) patients while the rest of the patients would have to pay out of pocket.
This meant that only 1.9 million households listed as BPL in the state would be covered under this and the rest would have to pay for the services.The Chhattisgarh government had separately identified and was already providing food support to nearly four million poor families (80% of the families in the state) (Puri, 2012).JSA questioned the government as to how they expected more than half of these families who they themselves had deemed requiring subsidised food grain, to pay for diagnostic services out of pocket.Furthermore, it was not clear as to how a private centre would be made to provide tests that are already free under various Government (disease control and maternal and child health) programmes.

Concerns regarding the concession to serve 'external' patients -
The proposal allowed the labs to serve external patients, i.e. private paying patients.JSA expressed concern that if the private laboratory that was located within the government hospital premises became entitled to take payment from some patients, they might make others pay too (Jan Swasthya Abhiyan Chhattisgarh, 2013).This went against the principles of providing free healthcare services and financial protection.
Mismatch between proposed diagnostic services and availability of specialists and doctors -JSA undertook a detailed analysis on the existing human resource available at the facilities and the corresponding diagnostic services being outsourced and found that in the proposal there were inconsistencies.For instance, in certain CHCs (e.g.Manendragarh) and new District Hospitals (e.g.Dantewada), there were hardly any specialists posted and most tests that were prescribed by the doctors posted, were being done.Therefore, providing higher diagnostic services through outsourcing in these facilities, without providing for doctors, would not lead to any meaningful improvement and additionally, the currently functioning labs would be rendered redundant.

Lack of monitoring and grievance redressal systems -
The RFP spoke of a 3 rd party monitoring mechanism.
The selection of the 3 rd party would have to be done through a bidding process.This meant making things more complicated as rather than dealing just with a set of one's own staff, the health department would then have to deal with two private agencies; one running the units and another one monitoring them.The performance parameters were also not articulated in the RFP.There was no mention of patient's rights, grievance redressal systems, community monitoring or any other systems of accountability that are important elements of governance and people's participation.
Experiences of other states ignored -Outsourcing of diagnostic services had been tried out in few states, Bihar being the largest model.The government's own criticism of diagnostic outsourcing in Bihar has been mentioned above (Ministry of Health and Family Welfare, 2012).Among other things, the evaluation report notes that while one hand the outsourced lab services were not functioning properly, there was high turn-around time, access to services had reduced, quality had reduced and costs increased, on the other hand, the in-house services (those being provided from before through government labs) were under-utilised, had become dysfunctional and the government lab technicians and radiographers had become redundant.It further recommended that the government should re-start its own facilities and that "out-sourced services should supplement the existing structure and public services, not become its substitute" (Ministry of Health and Family Welfare, 2012, pp.72-73).
In terms of best practices, Tamil Nadu state offered an example in contrast where, without any outsourcing the public health facilities, even the Primary Health Centres had been able to provide well-functioning diagnostic services (Pandey, 2015c).Nandi 683 However, in floating the RFP, Chhattisgarh government did not seem to have taken into account either the best practices or the negative experiences of outsourcing of diagnostics elsewhere.
Therefore, JSA raised the question that if this had been tried before in other states and had failed, then why was Chhattisgarh trying to repeat it, and that too at such a large scale (Jan Swasthya Abhiyan Chhattisgarh, 2013).
The experiences in other states showed that instead of improving and expanding the services already being provided by the government facilities, this initiative will completely destroy the existing services and replace them with privately and more expensively provided services and collection centers.Moreover, this was clearly not an 'interim' arrangement as the Agreement was to be done for ten years.Hence JSA contended that as the evidence clearly showed that there was hardly any rationale to outsource lab facilities at any level in Chhattisgarh in the present situation, this proposal had to be scrapped.

Getting the Message out
Equipped with the critique, an urgent state meeting was called on 11 th January 2013, of the civil society organisations (CSOs) who were involved with the JSA network.The next steps for the campaign were discussed and demands prepared.There was a consensus that this issue had to be taken up head on.JSA made the following demands to the government:

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Outsourcing of diagnostic services in public hospitals had to be stopped.

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Posts of lab technicians and radiographers needed to be filled as there were trained unemployed people available in the state.

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A twenty-five old recruitment rule that restricted recruitment of health workers needed to be modified.

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For the long term, local youth from marginalized communities and underserved areas needed to be trained and recruited as lab technicians and radiographers.

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Multiskilling training was needed for existing lab technicians so that they could undertake a variety of lab tests.

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Every health facility needed to be equipped with adequate human resource, equipment and supplies

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Public health services needed to be strengthened and not privatised.They needed to be made more responsive and accountable to people The critique and the demands were translated into the local vernacular Hindi, and also simplified so that everyone could understand what was at stake.Subsequently, the critique and JSA's demands were circulated to the media, both to the state (mainly Hindi) media and the national media.The submissions to media went with the message that JSA will resist this move of the government and was getting ready to unleash a state wide campaign against it.Within a few weeks, state and national media had covered the issue widely, along with JSA's critique and call to action against this proposal (Das, 2013;Pandey, 2015a).Meanwhile, the national JSA group was also informed of this proposal and support was garnered from them.Some suggestions on how to move forward came from them.

Petitioning and Submitting Memorandums to the Governor
In the meeting on 11 th January, it was also decided that JSA members from different districts would send petitions against this proposal to the Governor, the highest Constitutional post in the state.This was also a way to give government a chance to review their decision, before any explicit public action.JSA network organisations and activists from districts thus met the Collectors (district administrative head) and handed them the memorandums to be sent to the Governor.

Further Evidence Building
Meanwhile, a group of people within JSA kept collecting evidence on the availability of diagnostic services in the facilities that were listed in the proposal.A rapid survey of facilities was undertaken by an existing network of public health professionals who had access to government facilities.They were requested to send in information about availability of services in their facilities and the data was collated.An application under the Right to Information (RTI) law was submitted to the health department asking them on what basis had they made the plan, and to share any feasibility study that may have been undertaken before preparing the proposal for outsourcing.In responding to the RTI application, the technical agency stated that they had not be asked to prepare any feasibility study or value for money analysis by the government (SHRC Chhattisgarh, 2013).

Building Alliances With Trade Unions and Other Groups Working on Social Justice Issues
As JSA proceeded with the campaign, it built alliances with trade unions and organisations working on social justice, and not necessarily only on health.JSA members reached out to these groups.These groups were of two kinds-one were the unions of government health workers, lab technicians themselves, whose jobs were on line.The other were organisations that were engaged in struggles against forced displacement due to mining and industries, farming crisis and so on, which were an outcome of the same market-based policies of the government.
These groups seemed to find a common ground in this struggle against outsourcing of health services.Though the health worker trade unions were politically divergent and the one aligned with the ruling party did not want to be seen as actively opposing the government, they spoke up against the outsourcing in various fora, including in media.

State Level Rally and Press Conference
Realizing that visibility at the state level was required for the campaign, and that there was need to keep up the pressure, a rally cum public meeting and press conference was organized in state capital Raipur on 31 st January.
Civil Society Organisations (CSOs) mobilised people from the districts that they were working in.There was no funding specifically for this event and organisations and individuals used whatever funds they had, for this.Hundreds of people came from across the state.The police were in touch with JSA members throughout the day.The rally started from the railway station (where everyone had gathered) to the meeting venue at the heart of the city.Activists, community leaders and health workers came up to the dais and spoke about their concerns regarding the outsourcing.Slogans raised and written on placards reflected the mood of the assembly.
A memorandum, with a critique of the outsourcing proposal and demands on behalf of everyone assembled was given to a representative of the Governor who came to receive it at the meeting venue.
Simultaneously, few JSA Chhattisgarh members, that included well-respected activists and doctors, did a press conference at the Press Club.The events of the day were very well covered by all (Hindi and English) newspapers of the state, national media and international journal (Hitavada, 2013;Kay, 2013;Patrika, 2013a;Times News Network, 2013a).

District Level Events and Signature Campaign
At the public meeting it was discussed that the campaign needed to be taken back to the villages and districts.
The members assembled decided to hold district level events and undertake further dissemination of the outsourcing proposal, critique and demands.Activists visited health facilities and spoke to doctors and health workers, they stood at bus stands and market places and spoke to people about government's plan to outsource diagnostic services.They distributed pamphlets outlining the issue and the demands, written in a simplified manner and in the local language Hindi.A signature campaign was carried out against the outsourcing in villages and towns.
Then by April, when the government did not budge, sit-ins were organized at district headquarters.This time round the memorandums and petitions were addressed to the Chief Minister, the head of the government.These district events were covered widely by the local media in every district.These efforts resulted in further dissemination of information & solidarity building.

State Level Silent March
By May, there were no signs of government relenting.The bidding process too faced problems and was going slow.JSA decided that people had spoken enough and now it was the turn of the government to just listen.
Therefore a silent march was organised in the state capital Raipur on 19 th May 2013.Activists once again came from all over the state.They tied black bands over their mouths and marched carrying sheets of cloth with 1000s of signatures denouncing the outsourcing plans.It was visually very striking and the media covered the event, publishing photographs and JSA's demands (Naidunia, 2013;Patrika, 2013b;Times News Network, 2013b).

Representations to Sympathetic Bureaucrats in State and National Government
During the period of struggle, JSA activists made representations to bureaucrats who seemed sympathetic to the cause.An article criticizing the government's move was written by an ex-Health Secretary in a leading national newspaper (Rao, 2013).The governing board of the technical agency that was helping the government in developing the PPPs consisted of few people who were part of larger health rights and social justice movements.They pursued evidence-based critique of the proposal within the organisation.As a result the governing board registered displeasure at the agency and its leadership's role in promoting PPPs.They advised the agency to instead support the government to strengthen public services and subsequently changed the leadership.More recently, the technical agency has undertaken capacity building of lab technicians and provided other support in order to improve diagnostic services in the government facilities of Chhattisgarh, which has led to an increase in the number and type of tests being provided at government facilities (Tripathi & Garg, 2018).
JSA activists also approached certain politicians who were seen to be progressive.However, even though politicians and elected representatives may have been influenced by the media coverage and advocacy and played some role in reversing the government's decision, their role was not explicitly visible to the campaigners.
Others, who were in critical decision-making positions, especially regarding approving funds for this project, like bureaucrats in the finance department and the National Health Mission, were also sent representations.One of the outcomes of this was that the Government of India sent a team to study the proposal and make an assessment of the need for outsourcing diagnostics.The study team concluded that the proposal was flawed and was not based on the needs of the people of the state and that it may in fact do more harm than good (Pandey, 2015d).

Diagnostics Outsourcing Proposal Gets Stalled by Government
Under pressure from all directions and after failing to get financial approval either from the state finance department or the central government, in June the government announced that it was stalling the project (Bagchi, 2013c;Jaiswal, 2013).With this, the move towards outsourcing diagnostic services was halted for the time being.

Recent Developments
The Chhattisgarh government has once again, in August 2018, issued a Request For Proposal for outsourcing diagnostic services at various government facilities.Following previous processes, JSA has undertaken evidencebased critique of the RfP and tried to get the message out through writing in media (Nandi & Joshi, 2018) and issuing press statements (Jan Swasthya Abhiyan Chhattisgarh, 2018).

Lessons for Health Activism
The following section presents some reflections on the nature and efficacy of the strategies used and the lessons it has for health activism elsewhere:

Evidence-Based Critique
First step for the campaign was to analyse the proposal and provide a point-by-point critique along with evidence.
As it became clearer that the proposal itself had been prepared without any evidence base, JSA's arguments became stronger.The campaign made use of the network of CSOs and public health practitioners to collect and submit information about the availability of diagnostic services in the state.The network's base among organisations working in tribal areas, helped to bring forth the issues and data from areas that were being showcased as the main beneficiaries of the outsourcing proposal.JSA also brought in data from other states like Bihar where such projects were failing and used that to further critique the proposal (Jan Swasthya Abhiyan Chhattisgarh, 2013; Ministry of Health and Family Welfare, 2012).Moreover, the critique also tried to refute the larger rationale used for promoting privatisation of services and market-based policies, such as higher efficiency, equity and effectiveness, with evidence.The government tried to refute JSA's arguments through statements in media (Bagchi, 2013b).
However the government's arguments had a much weaker evidence base than the campaign's arguments and demands.It also helped that in the course of the bidding process, many of the arguments made by the campaign got proven (Bagchi, 2013a).For instance, when the private agencies did not apply for the more remote areas, the government's claim that outsourcing will bring these services to 'underserved' areas, was proven wrong.

Information as Power
Developing the detailed critique was possible only because the JSA activists could access the RfP.Though the RfP was posted on the health department's website, it was not easily searchable.Only those who were aware of the pathways to the site could access it.Once JSA activists accessed it, they converted it into simpler terms, so that everyone, and not only people with health or formal technical knowledge, could understand the issue.This was kept in mind even when drafting the critique and the demands.Once the documents were ready, they were then distributed.They were send to villages via the CSOs, and to media and bureaucrats.Throughout the campaign, JSA activists diligently circulated all the information and materials that was created as a result of the campaign.
For instance, media reports were circulated far and wide as soon as they appeared.Even though during that time Nandi 687 the network did not make use of any digital social media, the use of emails, two-pagers explaining the issue, personal interaction and media coverage helped to further spread the word.Accessing and disseminating the information was a very critical step in the struggle as often governments or the ruling dispensation don't 'allow' information about their plans to be known to people.As Foucault (1980) maintained, knowledge and power reinforce each other.However, disseminating the information was just one step, though a crucial one, which to lead to further collectivisation and action (Fox, 2015).

Use of Multiple Strategies, in Degrees and a Sustained Campaign
The action led by JSA was akin to what Tilly (2004, pp. 3-4) describes as a social movement that includes a combination of concerted and sustained campaign, multiple strategies and types of political action and public displays of "worthiness, unity, numbers and commitment (WUNC)".The campaign used multiple strategies, from petitioning to street action, to advocacy with media and bureaucrats.However these strategies were not used all at once.It was done step by step, starting from relatively 'milder' action like petitioning, and then going on to more 'aggressive' action, like street demonstration and subsequently the silent march.At every step there was stocktaking of what had been achieved and what had not, and then the next level of action was strategized, planned and undertaken.Different tactics were tried and different types of people and groups were approached for support.
There was no funding for this campaign and organisations involved in the network picked up costs as and when they could per their funds availability.The campaign went on for nearly six months, during which time the group of activists leading JSA Chhattisgarh at that time relentlessly followed up on each and every action and reaction that took for the government to finally back down.This highlights the importance of at least one group of people or organisation taking the leadership and persisting with the struggle.In this case, JSA Chhattisgarh was the group that led the struggle and others rallied around it.Though the core group was small, having this group constantly 'on the job' was critical.All of these activists were volunteers, doing this work in addition to their full-time jobs, which were mainly in related public health work.The government tried to discredit the campaigners saying that these were ideologically motivated 'left wing campaigns' (Bagchi, 2013a).

Privatisation and Neo-Liberal Policies as a Rallying Point
The issue of privatisation emerged as a common concern and a rallying point that brought together different kinds of people and groups.Tarrow (2011, p. 235) writes about 'global framing' which he describes as "the framing of domestic issues in broader terms than their original claims would seem to dictate".In the campaign too, the issue at hand, i.e. the outsourcing of diagnostic services, was thus framed.The broader alliances that were built over this campaign seemed to emerge from a concern regarding neo-liberal policies, its societal impact and the way it had negatively affected public provisioning of services (education, transport etc.), community's ownership over natural resources, labour rights and other dimensions of people's lives.As a result, trade unions and a number of organisations, such as those of indigenous people working on land and forest rights, who were not involved in direct health work, joined the campaign.So while these organisations may have considered healthcare as an important and relevant issue to intervene in, the concerns around marketisation and commercialisation of public goods provided the overarching solidarity.This was also reflected within the bureaucracy.Many within the bureaucracy believed that the government should be providing these services rather than outsourcing and this greatly strengthened the campaign's cause within the government.One lesson for activism from this is that the issue at hand is usually always related to larger, structural issues and issues of social justice that could be framed and articulated in order to form solidarity and broader alliances with groups working on those issues.This strengthened the campaign.

Posing the Issue in Terms of a Moral Argument
Another aspect closely related to the above point is that in addition to the evidence-based and technical critique against outsourcing of diagnostic services, the issue was also articulated as a moral issue.It posed the question as 'right' versus 'wrong' using the discourse of social justice and rights and the role of the state in protecting them.
This lent legitimacy to the campaign and helped mobilise people in large numbers.Posing the issue in this way also made it simpler for people to respond and react and lent "cultural resonance" to its framing (Benford & Snow, 2000, p. 622).

Active Role of the Media
Through the months of struggle, the media was mobilized and it played a big role in bringing the concerns of the campaign into public gaze and discourse.Both the national and the state media took up the issue repeatedly.In retrospection, the overwhelming support to the campaign from the local media seems to have been due to the strength of the campaign in being able to mobilise a large number of people and organisations on this issue and the larger concerns over privatisation, social welfare and social justice.Personal interactions with media persons at that time revealed that they were overwhelmed at the extent of mobilisation and campaigning and felt compelled to cover the issue.They further contributed to posing the issue in terms of vocabularies like 'privatisation' and 'selling of hospitals' which caught the public imagination.

Theoretical Implications
The fact that the government finally had to reverse its decision points to the success of the campaign.The strategies and processes of the campaign are concordant with the frameworks and theories of social movements and social activism.
The framing of the issue was undertaken by JSA, collectively with state and national units.Benford and Snow (2000, p. 615) write about the three core framing tasks, i.e. "diagnostic framing", "prognostic framing," and "motivational framing".For JSA, the goal of the campaign was very clear and uncomplicated, even in an operational sense, which was that the move for outsourcing diagnostic services had to be reversed.The problems with the proposed move, along with proposals for alternative steps that the government could take, were articulated with evidence.The strategies for action were planned and the persons or institutions that had to be approached were identified, both for making submissions and for building solidarity.The issue was raised as a moral issue and as indicative of other larger socio-economic policies, that had already negatively affected many of those who were involved in the struggle.The credibility of the framing was upheld throughout the campaign as it had consistency, was empirically sound and undertaken by a group of people who themselves had credibility (Benford & Snow, 2000).The issue of privatisation resonated among most who got involved, including bureaucrats.The 'global framing' of the issue that helped in this process has been similarly used by transnational campaigns against neoliberalism and globalisation (Tarrow, 2011).
The interactions with bureaucrats revealed that there are people within the government or the agencies that one is opposing, who may believe in the principles that the campaign is fighting for.Such people need to be identified and approached though they may be part of the very institution that the campaign is opposing, they often have the power to take decisions that could go in favour of the campaign demands.Klugman (2011) specifically writes of the need to influence bureaucrats and politicians as part of such advocacy.The campaign facilitated both collective action from below, influencing policy makers, leading to cohesive action towards the goal.Such action has been described in different frameworks as the 'sandwich strategy' (Fox, 2015) and 'nut cracker' effect (Baum, 2007).Klugman (2011) presents a model for strategising and evaluating advocacy process and social justice outcomes.
She argues that strengthened organisational capacity, support base and alliances that "draw on increased data and analysis from a social justice perspective" form the basis for effective advocacy (Klugman, 2011, p. 148).
Advocacy could be done within the 'corridors of power' or through peoples mobilisation, public action and media engagement (Klugman, 2011).This should lead to consensus building in a common definition of the problem and possible solutions that would further facilitate participation in advocacy and policy processes and also increase visibility of these views and issues (Klugman, 2011).
This paper narrates the story of a specific campaign against outsourcing of diagnostics in the state of Chhattisgarh.
But the campaign and the issue are embedded within the larger policy environment and political economy that defines social and public goods like health as a commodity and goods and services produced for sale (Deppe, 2009).Outsourcing of public services is being promoted as a desirable norm.The contestation remains between the ideas of 'providing' and 'purchasing', between the neoliberal and social justice approaches to health (Birn et al., 2009).However, the implications of market-based policies are becoming more and more visible and such policies are being resisted both globally and in India (Kishimoto & Petitjean, 2017).One set of (long term) outcomes that Klugman (2011) mentions is that of a shift in social norms through increased support for the views and positive change at the population level with respect to the issue under advocacy.As is evident from the recent developments in Chhattisgarh, this is where the work of PHM and other movements remain critical and relevant.The experience in Chhattisgarh shows that a campaign may be successful, but there is always the danger of reversal of the gain.

Conclusion
In Chhattisgarh, JSA was able to stall the privatisation of government diagnostic services and continues to try to do so.The success of the campaign has multiple lessons for health activism.Evidence based critique, effective framing of the issue, collective action from below and from policy makers from above, dissemination of information, use of multiple strategies, forging broader alliances and persistence were key elements for its success.It also highlights the need for health activism to continue beyond a single campaign.Staying vigilant, monitoring, evidence building, mobilizing people and continuing to build alliances on such issues are critical tasks for social movements and networks like the People's Health Movement.

Funding
The author has no funding to report.
Sustained campaigns, joint participatory and visible action, effective communication, knowledge building and coproduction through interaction between varied groups of people, developing common values and principles and building networks and broader alliances around issues of social justice are critical for health activism (People's Health Movement [PHM] & Third World Health Aid [TWHA], 2017).

Table 1
Salient Features of the Request for Proposal for Outsourcing Diagnostic ServicesOutsourcing of radiology and lab services in 379 government facilities was to be done.This included:

Number of facilities where outsourcing was to be done
• All 149 Community Health Centres (CHCs) in the state • 22 out of the 27 District Hospitals • Eight out of 17 Civil Hospitals • 200 of the better functioning Primary Health Centers (PHCs)