The Bhutanese Leading the way.
ACC investigating the procurement deal which violated procurement norms
Sources say specification of the machine should have been higher for better outcomes
In June 2016, there was an agreement signed between the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) and Care Australia, Kolkata of 12 years timespan to install and operate a Radiation Therapy unit for cancer patients in JDWNRH.
Although the Radiotherapy Services started from January 2018, however, it was discontinued 44 months later in 8 September 2021 when the doctors reported that the radiotherapy was sub-optimal or less effective in reducing the deep-seated cancer tumor sizes.
In the around 44 months, an average of around 350 patients would have got the treatment, and JDWNRH spent Nu 117.97 million (mn) as service and machine charges towards Care Australia based in Kolkata.
Sub-optimal quality
A medical source in JDWNRH said that the radiation therapy is mainly for deep-seated cancers that are difficult to reach like rectal, cervical, esophagus, head and lungs. The main aim of the radiation therapy is to penetrate the layers and reduce the size of the tumor, after which surgery can be done to remove the shrunken tumor.
However, doctors noticed that despite the radiation therapy, the tumors were not reducing in size, and in fact, the outcome for patients was not as good as when they were sent for the same radiotherapy treatment to Kolkata, before the machine entered the scene in JDWNRH.
In fact, in 2019, the Cancer Registry at JDWNRH showed a high cancer death rate from all types of cancers than in previous years, though there was no study done to prove the correlation between the lack of effectiveness of the radiotherapy and the deaths.
The matter came to light from 2021 when the former Director General of the Bhutan Narcotics Agency, Sonam Dorji, took over from 24 December 2020 onwards as the Interim President of JDWNRH.
The Health Flagship had some budget, and so the oncologists or cancer doctors at JDWNRH, worried about the sub-optimal results by the radiotherapy machine for deep-seated tumors, suggested upgrading the radiotherapy machine.
A puzzled new JDWNRH President asked for a justification on the need to upgrade it, and this is when the findings on how the machine was less effective with deep tumors started coming out.
A clinical study of a group of mainly 20 to 30 rectal cancer patients getting the radiotherapy showed that their tumor sizes were not reducing or were not obtaining the optimal response, normally seen after radiation, indicating poor treatment outcome.
The Interim President then informed the High-Level Committee of the Ministry of Health (MoH), and a decision was taken to discontinue the radiotherapy services from August 2021. The same High- Level Committee (HLC), chaired by Lyonpo Dasho Dechen Wangmo, noticed discrepancies in the procurement of the machine, and forwarded the case to the Anti-Corruption Commission (ACC) for investigation.
However, an administrative source from JDWNRH said that the report submitted by the doctors for 296 patients from January 2018 to December 2020 treated by the machine actually showed a sharply improving mortality rate, as in better survival rate. The official also pointed out that in 2020, when the lockdowns were in place, the machine was useful as it could provide treatment for the patients who could not travel abroad.
However, the medical source countered this saying that to know the complete mortality rate, data cannot be picked from three years but the complete data set at the Cancer Registry must be looked at. The source said the main point is that deep-seated tumors were not reducing in size, and mortality was not looked at.
The machine
A source in JDWNRH told the reporter that the machine installed by the company is an older 1990s generation machine that has been phased out in many hospitals around the world, except for maybe some countries in Africa.
The source said even hospitals in Siliguri have much better state-of-the-art radiotherapy machines. The source said that the only advantage of the machine is that it is cheaper to more state-of-the-art options.
A second source said that strength of the machine required for radiotherapy for deep-seated tumors is up to 15 MEV, but the the machine selected in the JDWNRH only had 6 MEV output.
Sources also pointed out that none of the oncologists at JDWNRH were consulted or involved in the procurement of the machine and its services, and they were only aware when everything had been installed.
The first source said, “If the doctors had been involved then they would have suggested better and more up-to-date radiotherapy machines with better specifications, but they were never kept in the picture.”
To add to this, the government procurement process was not followed as the contract was given directly to Care Australia.
This fact was borne out in an audit report on JDWNRH by the Royal Audit Authority (RAA) conducted in May and June 2022 for the financial year 1 July 2020 to 30 June 2021.
However, a third source in JDWNRH who is also familiar with the machine had a different take on the issue. This third source said the machine was not defective or faulty, but performed to its capacity of 6 MEV and a basic technology in it of using photons is the same as the more state-of-the art equipment.
The source said that before radiotherapy was done, there was a daily series of quality assurance safety checks done which was noted in a file, and all the time, the machine was performing as per its specification.
The source claimed that even if patients are referred to Kolkata, they would be mainly treated using the 6 MEV power.
The third source, however, admitted that the more state-of-the art machines could give more complex combinations of treatments, and machines with higher power above 6 MEV could be used for deep tumors.
The third source said, “If we compare it to cars, it is like the government has given us a small car but some people want it to perform like a Prado for certain cases. A Prado would be more expensive and comes with its own specifications, but basically, both are functioning cars. We were given a car and we managed with that.”
This source said that while the doctors have done efficacy studies, one has to look at a combination of factors.
The third source said if one only bought the machine then it would cost Nu 60 mn to Nu 80 mn in the market, but then the additional costs are quality assurance, parts, servicing the machine.
JDWNRH had not bought the machine outright, but was paying a monthly Nu 2.3 mn fee for the machine services, a clinical oncologist (radiologist) and a physicist sent by the company. The machine would remain with JDWNRH after 12 years.
Care Australia mystery
There is also a big mystery on why the company Care Australia in Kolkata used the name of an international charity organization in Australia known as Care Australia.
The Bhutanese wrote to the Care Australia office in Australia, and asked if they or their affiliates in Kolkata, India are involved in providing medical services to Bhutan for a fee.
Hayley Conway from CARE Australia said, “CARE Australia does not operate in Bhutan at all, and has not transferred any money for services of any kind. The organisation you refer to has no relationship to CARE Australia.”
However, at the same time, there is no evidence yet to indicate that Care Australia, Kolkata claimed to represent the real Care Australia.
While a lot of attention on the case has been focused on the former President of the autonomous JDWNRH at the time, Lhab Dorji, however, a former JDWNRH Board member said that it was not Lhab Dorji who introduced Care Australia, Kolkata to the Board, but the former JDWNRH Director Sonam Phuntsho.
Sonam Phuntsho had been the Director there for a while, and Lhab Dorji had been appointed later from December 2014 onwards.
The paper reached out to Sonam Phuntsho to reply to this allegation, but he said he needs to look at some papers, and he did not respond back.
The claim from a former senior official involved in the issue is that there was no one interested in providing the service, given the low number of patients in Bhutan, and so JDWNRH got in touch with Bhutan Chamber of Commerce & Industry (BCCI) to find if there are any Bhutanese business counterparts interested in supplying the service. There was, again, no interest shown there.
It seems that Care Australia then came into the picture.
What made RAA suspicious, and the HLC too, is that there is no paper trail to show that JDWNRH floated notifications in the media, inviting companies for the service or followed a proper procurement process at all.
But suddenly Care Australia got in, and was making presentations to the JDWNRH board.
Meantime, Care Australia, Kolkata, ever since the 2021 suspension, has been wanting to come to Thimphu to find out if there was any fault with them. After insisting several times that they want to come to discuss matters with JDWNRH, the company has been given a date of 27 to 30 December 2022 to meet for discussion.
A source in RAA said that the machine purchase would not have ended up like this, had the proper process been followed and consultations done. This is wastage of resources, the source added.
ACC Investigation
ACC is now investigating the whole deal for corrupt practices.
ACC is talking to the senior officials of the JDWNRH at the time, and is also talking to the JDWNRH board members.
The Health Minister Dasho Dechen Wangmo who heads the ELC said the Technical Committee that was entrusted by HLC to look into the case said the treatment effectiveness was not there, and there was no due diligence done for the procurement of the machine.
The radiotherapy service came in after policy guidelines were issued in 2014 by MoH to have such a service in the country, and reduce the inconvenience for patients who had to go all the way to Kolkata.
It was a part of the then policy to try and give cancer care within Bhutan, and also in the backdrop of a proposal to the GoI to build a cancer hospital in Bhutan.
RAA findings
According to RAA, under the agreement signed between the two, the cost every month was divided into Nu 1.3 mn for machine charges and Nu 1 mn for service charges with a 3 percent increase every year. So, from 2016 to mid 2021, Nu 72.14 mn was paid as machine charges while Nu 45.83 mn was paid as service charges.
RAA said the Nu 117.97 mn did not provide value for money.
RAA said a review of MoU, board meetings and other related documents, for establishment of radiation therapy service, revealed that detailed need analysis and proper feasibility studies were not conducted.
Further, as per the Minutes of the 3rd Board Meeting held on 30 July 2015, the Board had asked the management to study on pros and cons and detailed cost-benefit analysis for taking appropriate and informed decisions by the Board. However, the feasibility studies of pros and cons and the cost-benefit analysis were not conducted for the establishment of radiation therapy service.
Despite any such studies being conducted, the 4th Board Meeting held on 18 May 2016 approved the establishment of radiation service in JDWNRH, without exercising proper due diligence.
Further, Section 8.4 of the National Health Policy 2011 states that no new health technology should be allowed until assessment and evaluation for its safety, efficacy, quality, indication, and cost-effectiveness are conducted by the health technology assessment panel.
However, such basic requirements for the establishment of new technology in the country were not followed.
The Board and JDWNRH management had directly awarded the Service contract to M/s Care Australia, Kolkata for installation and operation of Radiation Therapy Service without following procurement norms in deviation to the Clause 4.1.1.2, Chapter IV of the Procurement Rules and Regulations 2009. The direct award of contract had not only deviated from a fair and equitable opportunity to all the prospective bidders, but also deprived the management from the competitive rates.
RAA said it could not rule out the possible collusion with M/s Care Australia (Sole Proprietor) as it was directly identified as a service provider by the Board and JDWNRH management. Therefore, the proper investigation should be carried out, and accountability fixed on the officials responsible for the gross lapses.
In response to the above, the current JDWNRH management said in absence of the report, they are not sure how the Board approved the services.
“Since we failed to trace the document (in case it exists), the current JDWNRH management is not able to justify why the study was not carried out. Therefore, the justification for failure to comply with the recommendation may be sought from the individuals involved,” said JDWNRH management.
RAA said that in deviation to the agreed service terms, JDWNRH paid Nu 11.650 mn to M/s Care Australia from March 2017 before it started treating the patients using the radiation service. From the records furnished to RAA, the treatment of patient using the radiation service commenced from January 2018.
RAA said some of the critical deliverables agreed in the Agreement by the the service provider were not delivered.
Introduction of a PG Diploma in Oncology for two years was withdrawn in the revised MoU, fellowship training in radiation oncology in India (tuition fee for the course to be paid by the service provider) was not provided, and no “TUMOR BOARD” was organized for those cancer cases where the clinical oncologist is not comfortable to take an independent decision regarding cancer patient’s treatment protocols.
There are also no records to show that the service provider has contributed towards the National Cancer Registry in Bhutan for statistical analysis, and interpretation of database collected as and when needed by JDWNRH/Ministry of Health.
No Surgical Oncologist was deputed to the JDWNRH on surgical duties for one week every month as required by the Service Agreement. Only Clinical Oncologist (Dr Partha Sen) was deputed.
The RAA found laxity on the part of management to enforce contractual terms, but continued to pay huge monthly charges to M/s Care Australia without receiving agreed deliverables as per the Service Agreement.
Legal and financial troubles ahead for JDWNRH
An official from JDWNRH said that the Care Australia, Kolkata has indicated that they want financial compensation, in terms of the machine charges per month for the remaining years, which is around Nu 84 mn.
There are also chances that the company may take the matter to court, as violation of the contract, at which point the two questions is; if JDWNRH has taken the adequate precautions while drawing up the contract, and if JDWNRH can technically prove that something is wrong with the machines.
