How Punjab and the centre allowed hundreds of PM-CARES ventilators to lie unused for months

In May 2020, Gurpreet Singh Chandbaja, the founder of a non-profit that works with cancer patients, first raised the issue of unused ventilators at the Guru Gobind Singh Medical College and Hospital, in Punjab’s Faridkot district. He spoke to the medical superintendent about the unused ventilators, which were among 809 units that the centre had allotted to Punjab under the PM-CARES fund. Over the next year, Chandbaja visited the hospital multiple times, and saw more ventilators gathering dust each visit. Finally, in May this year, Chandbaja took a photo of dozens of unused ventilators in the hospital, which made its way to Kultar Singh Sandhwan, the Aam Aadmi Party’s member of legislative assembly from Faridkot’s Kotkapura city. Sandhwan tweeted the image on 11 May. Soon after, news broke that the Punjab government was yet to install or repair hundreds of unused ventilators.

The Congress-led Punjab government, on its part, has blamed the central government for providing faulty ventilators under the Prime Minister's Citizen Assistance and Relief in Emergency Situations, or PM-CARES, fund. In May 2020, the centre had announced the allocation of Rs 2,000 crore for the manufacture of 50,000 “Made-in-India ventilators.” As of April this year, Punjab had received all 809 units, but at least 251 of them were uninstalled, according to the central government. The state, meanwhile, has claimed that a large number of PM-CARES ventilators in the state are either out of order, or lying unused because doctors had found them to be unreliable.

The union health ministry, on the other hand, has maintained that the ventilators are in working condition and simply need to be operated properly in accordance with the user manual. In its defence, the centre has pointed out that engineers who have been deputed to Punjab to install the ventilators have found them to be in working condition, which just needed to be set up as per the instructions. In support of its argument, the centre noted that on 12 May—the day after Sandhwan tweeted the image—an engineer visited the Faridkot hospital and made five ventilators functional only by replacing a few components as stated in the manual. “Thereby, further making it evident that when operated properly, the ventilators will provide reliable performance,” a central government press release stated.

It is not entirely clear which government is responsible for hundreds of ventilators left uninstalled or unrepaired at a time when patients are gasping for breath as they try to find a bed in an intensive-care unit equipped with ventilators. By most indications, the fault does not lie entirely with one government, but with both of them for continuously passing the buck. Indisputably, while Punjab and the centre played politics for months, the ones who suffered the consequences were the patients whose lives were at stake.

Chandbaja is the founder of the Bhai Ghannaya Cancer Roko Sewa Society, which is based in Faridkot, and frequently visited the Guru Gobind Singh hospital to help cancer patients with medication and chemotherapy even during the pandemic. Chandbaja told me that he had first raised the issue of unused ventilators in the district’s Guru Gobind Singh hospital in May 2020. However, Shilekh Mittal, the medical superintendent at the hospital, told me that the first batch of PM-CARES ventilators arrived only in June, which would suggest that the hospital previously had unused ventilators of its own that it had not repaired since the first wave of the pandemic.

After seeing a drop in cases for one month in May, in June 2020, cases in Punjab began to rise once again. From 231 active COVID-19 cases on 1 June, the state had nearly 5,000 cases by 1 August. As of 31 July, the state’s official health bulletin recorded 135 patients on oxygen support and 18 on ventilator support. During this period, ventilators manufactured under the PM-CARES fund began to be released to various states.

On 23 June, the central government issued a press release with details of the 50,000 “Made-in-India ventilators”—30,000 were being manufactured by the state-owned Bharat Electronics Limited, and another public-sector undertaking, HLL Lifecare Limited, had issued purchase orders for the rest. The press release noted that 1,340 ventilators had been allocated to states, though it did not mention how many were allocated to Punjab by then. By the next month, a right-to-information application revealed that two of the firms that received HLL’s purchase orders were dropped from the health ministry’s list of manufacturers after failing a clinical evaluation. The RTI response, dated 20 July 2020, revealed that only two companies apart from BEL were manufacturing ventilators under the PM-CARES fund—Allied Medical and AgVa Healthcare—and the total number being produced had come down to 40,350.

As Punjab continued to receive ventilators under the PM-CARES fund,  the number of unused ventilators at the Faridkot hospital kept increasing as well, according to Chandbaja. He told me that in the initial months that he noticed the ventilators, he only brought it up with doctors at the hospital and did not raise his concern to politicians or the media because he did not want to further burden the healthcare staff dealing with the pandemic. “I kept getting this information from the patients’ relatives about more and more ventilators having been dumped in the hospital,” Chandbaja told me. “I once again took up the matter and was assured that the needful would be done. The medical superintendent was very much acquainted with the issue and our demand too. We did not want the doctors to feel pressurised in any way so trusted the word given to us.” But during subsequent visits, he kept seeing more ventilators lying unused, while the pandemic continued to rage across the country.

In August, Chandbaja’s non-profit and other groups began taking the issue to the media and politicians, he told me. He said a press conference was held by various organisations about the unused ventilators on 29 August, in Faridkot, and that a representation was sent to three members of the Punjab legislative assembly two days later. On 8 September, Chandbaja said, a delegation of farmers’ union leaders also met the medical superintendent of the hospital, but the ventilators remained unused.

In Punjab, the allocation of ventilators for government medical colleges comes under the purview of the state’s department of medical education and research, which is headed by the minister Om Prakash Soni. Chandbaja told me that he had raised the issue with Soni directly, on 15 March this year. “Soni constituted a committee on 16 March,” Chandbaja said. “There was another meeting on 17 March with the medical college authorities, and another meeting held with district officials on 6 April.” Finally, on 11 May, when Chandbaja and the senior vice-president of his organisation, Kultar Singh, “saw 14 such ventilators in a corner and one even in the ICU, it was then that we raised the issue.” At this point, amid the devastation caused by the second COVID-19 wave, the administration appears to have been triggered into some action. Soni spoke to the union health minister, Harsh Vardhan, on the next day, who then informed the media that a team of experts would be dispatched to fix the ventilators. On 13 May, the health ministry issued a press release stating that the ventilators were not malfunctioning. 

When I called Soni in May this year about Chandbaja’s allegations, he directed me to speak to Sanjeev Sharma, the officer-on-special-duty to the minister. Sharma corroborated Chandbaja’s account that a majority of ventilators at Faridkot were out of order. He said that out of the 809 ventilators received under PM-CARES by Punjab, 320 were allocated to three government medical college and hospitals—113 to the Guru Gobind Singh hospital in Faridkot, 109 to the Guru Nanak Dev hospital in Amritsar, and 98 to the Rajendra Hospital in the Government Medical College, Patiala.

Of these, Sharma told me, 90 of the 113 ventilators at Faridkot were out of order, 97 out of the 109 in Amritsar were out of order, and only 12 ventilators in Amritsar were functioning. According to Sharma, 48 ventilators in Patiala were repaired, but the doctors at the hospital have refused to use them because of a lack of confidence in the ventilators. As a result, Sharma said, the hospital was using 61 ventilators that it had before the pandemic. In total, out of 320 ventilators that had been allocated to these hospitals by September 2020, only 47 ventilators—less than 15 percent—were functioning and in use even as late as May this year.

But Punjab’s health authorities have maintained that these issues were repeatedly brought up before the centre, and that their concerns were repeatedly ignored. On 17 September, Hussan Lal, the principal secretary in the state health department, wrote to Rajesh Bhushan, the union health secretary, about “complaints regarding functioning of ICU ventilators supplied through M/s BEL by the Government of India.” Lal wrote that that the state had received ventilators manufactured by BEL and allocated them to government and private hospitals, which soon began complaining about them malfunctioning.

“Regretfully, initially the pace of installation of these ventilators was extremely slow since only one engineer was allocated by the supplier for installation,” Lal wrote. “After repeated follow up with ministry as well as the suppliers’ representatives, the installation process was expedited. Now the hospitals where these ventilators have been installed are complaining regarding functioning of these ventilators.” Lal requested the union secretary to “take up the matter with the supplier,” and sought directions to BEL to “put in place a proper mechanism to redress the regarding functioning of ventilators within time bound manner, by ensuring close to 100% uptime.”

Lal did not respond to queries about their correspondence over the unused ventilators. Manisha Verma, the additional director general of media and communications for the health ministry, asked me to send my queries to the email address of the Press Information Bureau’s health division. The PIB Health team responded directing me to the press releases issued by the health ministry. I pointed out that the press releases did not address my queries, and received no response by the time this piece was published.

Tanu Kashyap, the managing director of  Punjab Health Systems Corporation—a statutory body responsible for expanding and improving medical care in the state—also told me that the state government had made several efforts to address the issue. Kashyap is also the nodal officer responsible for coordinating all issues related to ventilators in the state. I spoke to her on 14 May. She told me that that the state health authorities had been taking up the matter with their counterparts at the centre since last year, both verbally as well as in writing. “In the video conferences, we did share about 200 ventilators lying unused especially since the ones installed were not working and installation itself was an issue. We urged the centre officials to take these back, but they refused,” Kashyap said.

The centre, meanwhile, has consistently blamed the Punjab government for being unable to operate the ventilators and for having an inefficient health infrastructure that could not support the ventilators provided under the PM-CARES fund. It has also raised its concerns with the state government. On 11 April, Bhushan wrote to Vini Mahajan, the Punjab chief secretary, over the non-installation of 251 ventilators out of the 809 provided to state. Bhushan’s letter noted that the health ministry had provided the ventilators for the management of the COVID-19 pandemic and that the non-installation “defeats the very purpose of this exercise by the Government of India.” The ministry urged the Punjab government to install and operationalise the ventilators as soon as possible, adding that “if there is any additional requirement of ventilators, the same may be intimated to the Ministry of Health within next one week.”

One of the central issues behind the failure to set up the ventilators appears to be a lack of consensus between the governments on where the responsibility of installation and servicing lies. While the centre seems to maintain that it has provided the numbers of the manufacturers and the onus of installation and repair lies with the state government after the ventilators are supplied, the Punjab health authorities have repeatedly expressed helplessness and called upon the centre and BEL to install and repair the machines.

But according to Kashyap, even amid the second wave, doctors at Punjab’s hospitals were hesitant to use the ventilators provided under the PM-CARES funds. Kashyap, like Sharma, said that 320 ventilators were provided to government medical colleges, and the rest were distributed among other district hospitals across the state, both private and public. But in all cases, she added, even the functioning ventilators were not being used. “Doctors are not ready to risk patients’ lives since many of these ventilators stopped working in the initial two- three hours itself,” Kashyap told me.

According to a senior Punjab health official who spoke on the condition of anonymity, it was not just the doctors who were uncomfortable about using these ventilators, even the state government was sceptical about them. The health official said that the state does not have the required anaesthetists, pulmonologists and even the necessary trained paramedical staff—including nurses, ward attendants and technicians—to operate the ventilators and ICU beds. As a result, the health official added, the state government started giving these ventilators to the private hospitals, but they were equally wary of using these.

An owner of a private hospital in Amritsar told me that the state had approached their hospital to take the ventilators. “But we sensed something fishy since by then the news of faulty ventilators and the government trying to rub these off to private hospitals in the wake of shortage of staff had reached all doctors,” the hospital owner said, speaking on the condition of anonymity. “So we did not take any of this junk.”

Dr Raj Bahadur, the vice chancellor of the Baba Farid University of Health Sciences—under which the three government medical colleges at Faridkot, Amritsar and Patiala function—also said that the poor quality of these ventilators scared the doctors. “The very moment we installed them, the ventilators stopped working,” Bahadur said. When I spoke to him on 14 May, he told me that he had informed the authorities of these snags about two and a half months back. So far, Bahadur added, they had repaired 28 ventilators but the medical colleges were insisting on using the ventilators that they had previously.

However, he did not seem particularly concerned about the hundreds of ventilators gathering dust. Bahadur said that Patiala has 61 ventilators of its own from before the pandemic, Amritsar has 39 and Faridkot has 42, and seemed to suggest that these were sufficient. “The doctors are the ones to decide whom to put on ventilator and who requires just oxygen supplementation,” he told me. “Those who are put on ventilators are not the ones who survive. Just five percent of the patients put on ventilators are able to make a comeback.” It is unclear why the five percent of patients did not spur Bahadur to take more serious action about the unused ventilators.  

On 1 May, Lal wrote another letter, this time to Mandeep Kumar Bhandari, a joint secretary in the health ministry, stating that “the responsibility to install and provide after sale services rest with M/s BEL.” He added that there were “a number of complaints regarding malfunctioning of these ventilators” and that “ventilators have not been installed at some of the locations even till date.” Lal said that the state government had approached “representatives from the company … time & again to get the malfunctioning ventilators repaired,” but to no avail.

He emphasisedthe urgency of the ventilators because the “state is in the grip of severe second wave of COVID.” Lal continued, “Even the Service Engineers, the Technical Personnel who are deputed to take care of after sale service say they do not have the requisite spares and the consumables. In view of the malfunctioning of the ventilators and some of the ventilators not even installed, non-availability of the spares & consumables, the state is finding it difficult to manage serious COVID patients requiring ventilatory support.”

It is unclear why Lal waited till May, several months into the second wave, to send this letter. He did not respond to queries by the time this article was published.

Eight days later, Bhandari, the joint secretary in the union health ministry, wrote to health secretaries of all the states, underlining that the ventilators provided under the PM-CARES fund “are precious national assets, and that it is important that their optimal usage is ensured for COVID-19 patients.” He provided email addresses and phone numbers of the ventilator manufacturers and called upon the states to “undertake quick verification of the ventilators provided to them and to ensure that they are put to optimal use.” Bhandari added, “The bottlenecks in their installation and optimum performance may also be got verified and addressed.”

The joint secretary also pointed to reasons for the failure of states to install the ventilators, which clearly shifted the onus from the centre to the state governments. “This might be on account of various reasons,” Bhandari wrote, “including lack of trained and skilled manpower for using them, improper handling of the devices, lack of proper connection with the oxygen pipeline, lack of optimum oxygen pressure, non-allocation of hospitals and keeping as spare stock in ware houses, lack of arrangement for procuring consumables, etc.”

Four days later, in the wake of news reports about unused ventilators in Punjab, the health ministry issued a press released titled, “Update on Ventilators Supplied under PM CARES.” The press release termed the media reports about unused ventilators in the Faridkot hospital as “unfounded, not having the full information on the matter.” It added that BEL “engineers have visited the said Medical College on different occasions in the past to address the complaints received and carried out minor repairs required promptly. They have even conducted repeated demonstrations of the functioning of the ventilators to the staff over there.” To substantiate this argument, the ministry noted that BEL engineers visited the Faridkot hospital again on 12 May and made five ventilators functional only by replacing a few components, “further making it evident that when operated properly, the ventilators will provide reliable performance.”

The statement continued, “In addition to the instructions given in the user manual, detailed instructions and guidelines have also been issued to all the ventilator users regarding infrastructure requirements, proper usage and maintenance of the CV200 ventilators.” The CV200 ventilators are the ones manufactured by BEL. “However, these are not being followed by many hospitals / medical colleges in Punjab. “They have been, instead, raising the issue of ventilators being non functional without any basis.”

The press release then reproduced the 9 May letter by Bhandari. Kashyap, Punjab’s nodal officer for the procurement of ventilators, however, has maintained that in the eight months since Lal sent the letter in September, only one engineer had been sent to Punjab for rectifying these ventilators, until the team was sent on 12 May.

Punjab is not the only state to have raised concerns about the ventilators provided under the PM-CARES fund. In April this year, the Indian Express reported that the Rajasthan government had also written to the centre over “faulty” ventilators. According to the report, the issue was first raised during a COVID-19 review meeting chaired by the state’s chief minister, Ashok Gehlot, on 5 April. The report quotes Dr Lakhan Paswan, the principal of the Ravindra Nath Tagore Medical College in Udaipur, “We had received 85 ventilators under PM Cares and apart from ours, the feedback from other medical colleges is that they are not effective.” Paswan appears to have raised similar concerns to those raised by Punjab’s health officials, stating that “Our anaesthetists and intensive care doctors of medicine (department) don’t have confidence in PM Cares ventilators at all. The ventilators run for 1-2 hours and then they stop working.”

Moreover, after the news of Faridkot’s ventilators broke, India Today reported that 43,788 ventilators manufactured under the PM-CARES fund had been dispatched to states as of 6 April, and that only 38,803 of them had been installed. The report also noted that when a team of BEL engineers visited Punjab to repair the ventilators, “they found that the hospital had no connectors for their piped oxygen gas system to link the machines.”

The Punjab government’s position holding the centre and the manufacturer’s responsible for the unused ventilators is also severely dented by the fact that amid the exchange of letters, the state government issued a press release claiming credit for the 809 ventilators. Issued on 2 May this year, the press release began, “Taking another step towards facilitating the critical Covid patients gasping for life and in order to further ramp up the health facilities to conquer the devastating second virus surge, the Punjab Government has provided 809 more ventilators to the districts in the state.” It further stated that the state’s chief secretary Mahajan had “directed all the Deputy Commissioners to install the new ventilators today itself and ensure that not even a single oxygen concentrator and ventilator remain unutilised.”

It is unclear how the state government can direct deputy commissioners to install the ventilators on the one hand, and seek to blame the centre and the manufacturers for failing to install them on the other. Mahajan declined to speak on the topic and directed me to speak to the joint secretary Lal, who did not respond to queries.

In the wake of all this uncertainty, on 13 May, Satnam Singh, the president of the non-profit Punjab Against Corruption wrote to the president of India and the Central Bureau of Investigation demanding a first-information report in the case. The complaint called for a probe by a special investigation team into all the individuals “responsible for buying and clearing quality standards of faulty and substandard ventilators during this pandemic.” Singh added, “Awaiting URGENT action to save many more patients dying due to this.”

On 24 May, Punjab recorded 2,509 new COVID-19 cases and 187 deaths.