Government of India is committed to the goal of ‘Health for All’ The obligation of the Government to ensure the highest possible health status of India’s population and access to quality health care has been recognized by a number of key policy documents.Health care system supplement in improving the health of individuals, particularly those belonging to socially and economically disadvantaged groups,which is a key objective of the Indian government and a major consequence of a Constitution.
Recognizing the importance of Health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system.
Mission of Madhya Pradesh aims at providing the necessary knowledge and skills to keep all rural people living in the state of Madhya Pradesh to ensure equitable, accountable and effective primary health care especially to the poor women and children and to promote the quality of their lives. And to enable them to lead a healthy productive life. Thus, there are two main components of the Programs: To provide the knowledge needed to keep the first people healthy and empower the people living in the state, secondly, Madhya Pradesh has adopted the vision adopted by the National Health Mission, Government of India. In order to keep the people healthy, the necessary skills and knowledge are being provided throughout the state and the villagers of the state Provide effective health services for the population to be strengthened to poor infrastructure and as worst performing districts.
Under Universal access to basic health facilities consisting of health card, medical examination following programs / facilities have been initiated by Central and State Government in Uttarakhand:-
- National Rural Health Mission (NRHM)
Healthcare Facilities in Rural Areas
- indigenous systems of medicine; drugs and pharmaceuticals. Public health being a State subject, the primary responsibility to provide improved access to healthcare services is that of the State Governments. However, under National Health Mission (NHM) financial support is provided to State/UT Governments to strengthen their healthcare systems to provide better and easy access to healthcare services. As per Rural Health Statistics, 2014, there is a shortfall of 36346 Sub Health Centres (SCs), 6700 Primary Health Centres (PHCs), and 2350 Community Health Centres (CHCs) against the specified population norm.
- As per Rural Health Statistics Bulletin (RHS) 2014, a total of 2225 (8.89%) Primary Health Centres (PHCs) are functioning without doctor, 9825 (39.26%) PHCs without Lab Technician and 5739 (22.94%) PHCs without a pharmacist in the country.
- Under the National Health Mission (NHM), financial support is provided to the States /UTs to strengthen their health care system for augmentation of health human resources, provision of free essential medicines, etc. Some key support areas under NHM are:-
- ASHAs: ASHA is a female voluntary health worker who acts as the link between the community and the public health facilities. She provides basic information regarding health and health care services and motivates people to access services from public health facilities.
- Ambulances: Under NHM, support is provided to States/UTs to set-up a patient transport system where people can dial 108 or 102 telephone number for calling an ambulance. Dial 108 system is an Emergency Response System, primarily designed to cater to patients of critical care, trauma and accident victims, etc. 102 services is essentially the basic patient transport system aimed to cater to the pregnant women and sick children though other categories are also taking benefit and are not excluded.
- Mobile Medical Units (MMUs): MMUs provide outreach services in rural and remote areas through a team of staff including one doctor, one nurse, one lab attendant, one pharmacist and a helper and driver.
- Human Resources: Support is provided under National Health Mission to States and UTs for engaging health care staff at public health facilities on contractual basis, for providing incentives to doctors and other staff to work in rural and remote areas, for capacity building of staff, etc.
- Infrastructure: Support under NHM is provided to States/UTs for establishment of new facilities based on population and time to care norms and for up-gradation of existing facilities by constructing new buildings or by renovation of existing ones.
- Drugs & Equipment: To supplement the efforts of States/UTs in ensuring availability of drugs at public health facilities, Government of India has been providing free drugs /funds for free drugs to States/UTs under the Reproductive and Child Health (RCH) and National Disease Control Programmes for Tuberculosis, Vector borne diseases including Malaria, Leprosy and HIV/AIDS etc. Government is also encouraging the States/UTs to provide universal access to free essential medicines in public health facilities by providing funds and incentives under the National Health Mission (NHM). Up to 5% additional funding (over and above the normal allocation of the state) under the NRHM was introduced as an incentive from the year 2012-13 for those States that introduce free medicines scheme.
- Untied Grants to facilities: Under NHM, support is given to States/UTs to strengthen Sub Centres, PHCs, CHCs and District Hospitals by provision of Untied Funds to undertake need based works for improving infrastructure and enhancing service delivery at these facilities.
- Support for Reproductive, Maternal, New-born, Child & Adolescent Health (RMNCH+A): RMNCH+A seeks to address the major causes of mortality among women and children as well as the delays in accessing and utilizing health care services. The RMNCH+A strategic approach provides for ‘continuum of care’ to ensure equal focus on various life stages. The support to States/UTs under National Health Mission for RMNCH+A includes Janani Suraksha Yojana (J.S.Y), Janani Shishu Suraksha Karyakram (J.S.S.K), Maternal and Child Health Wings at facilities with higher case load, Integrated Management of Neonatal and Childhood Illness (IMNCI), Home Based New-born Care (HBNC), establishment of facility- based care for new-born and sick children including New Born Care Corners (NBCCs), New Born Stabilization Units (NBSUs), Special New Born Care Units (SNCUs), Nutritional Rehabilitation Centres (NRCs), Universal Immunization Programme, Rashtriya Bal Swasthya Karyakram (RBSK), Rashtriya Kishor Swasthya Karyakram and Family Planning Services.
- Support for control of communicable and non-communicable diseases: Under NHM, support is provided to States/UTs for the control of the communicable diseases including vector borne diseases such as Malaria and Filariasis, Leprosy and Tuberculosis and for disease surveillance. Under the National Non-Communicable Disease Programmes, NHM supports prevention and control of Blindness, mental health issues, cardiovascular diseases and stroke, deafness, Tobacco related illnesses, oral health issues, Fluorosis, Iodine deficiency disorders, etc. In addition support is also provided to States/UTs for health care of elderly and palliative care.
.The key core strategies under NRHM are :
- Train and enhance capacity of Panchayat Raj Institutions (PRIs) to own, control and manage public health services.
- Promote access to improved health care at household level through the village level worker , ASHA
- Health plan for each village through Village Health Committee of the Panchayat.
- Strengthening sub centers through better human resource development, clearquality standards, better community standards, better community support and an untied fund to enable local planning and action and more multipurpose workers.
- Strengthening existing Primary Health Centers through better staffing and human resource development policy, clear quality standards, better community support and an untied fund enable the local management committee to achieve these standards.
- Provision of 30 – 50 bedded CHC per lakh population for improved curative care to a normative standard. (Indian Public Health Standards defining personnel,equipment and management standards)
- Preparation and implementation of an inter-sector district plan prepared by district health mission, including drinking water supply, sanitation, hygiene and nutrition.
- Integrating vertical health and family welfare programmes at national, state,district and block levels.
- Technical support to national, state and district health mission for public health management.
- Strengthening capacities for data collection, assessment and review for evidence base planning, monitoring and supervision.
Supplementary Strategies under Mission
- Regulation for private sector including the informal Rural Medical Practitioners(RMPs) to ensure availability of quality service to citizens at reasonable cost.
- Promotion of Public Private Parternership for achieving public health goals.
- Mainstreaming the Indian System of medicine (AYUSH) revitalizing local health traditions.
- Reorienting medical education to support rural health issues including regulation of medical care to medical ethics.
- Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable and good quality hospital care.
Primary health care resources in India
Infrastructure
Health Infrastructure is an important indicator to understand the healthcare delivery
provisions and mechanisms in a country. Health Infrastructure indicators is subdivided
into two categories viz. educational infrastructure and service infrastructure.
Educational infrastructure provides details of medical colleges, students admitted to
M.B.B.S. course, post graduate degree/diploma in medical and dental colleges,
admissions to BDS & MDS courses, AYUSH institutes, Nursing courses and Paramedical courses.
Medical education infrastructures in the country have shown rapid growth during the last
20 years. The country has 314 medical colleges 46 with total admission of 29,263 (in 256
Medical Colleges), 289 Colleges for BDS courses and 140 colleges conduct MDS
courses 21547 and 2,783 respectively 47 during 2010-11. There are 2028 Institutions for
General Nurse Midwives with admission capacity of 8033248 and 608 colleges for
Pharmacy (diploma) with an intake capacity of 36115 49 as on 31st March, 2010.
Service infrastructure in health include details of allopathic hospitals, hospital beds,
Indian System of Medicine & Homeopathy hospitals, Sub centers, PHC, CHC and blood
banks.
There are 12,760 hospitals having 576793 beds in the country. 6795 hospitals are in rural
area with 149690 beds and 3748 hospital are in Urban area with 399195 beds. Rural and
Urban bifurcation is not available in the States of Bihar and Jharkhand.
Medical care facilities under AYUSH by management status i.e. dispensaries & hospitals
are 24,465 & 3,408 respectively as on 1.4.2010.There are 1,47,069 Sub Centers, 23,673 Primary
Health Centers and 4,535 Community Health Centers in India as on March 2010. Total No. of
licensed Blood Banks in the Country as on January 2011 are 2445.
Sub Centres (SCs)
The Sub-Centre is the most peripheral and first contact point between the primary health
care system and the community. Each Sub-Centre is required to be manned by at least
one Auxiliary Nurse Midwife (ANM) / Female Health Worker and one Male Health
Worker (for details of staffing pattern, and recommended staffing structure under Indian
Public Health Standards (IPHS) see Annexure I). Under NRHM, there is a provision for
one additional second ANM on contract basis. One Lady Health Visitor (LHV) is
entrusted with the task of supervision of six Sub-Centers. Sub-Centers are assigned tasks
relating to interpersonal communication in order to bring about behavioral change and
provide services in relation to maternal and child health, family welfare, nutrition,
immunization, diarrhoea control and control of communicable diseases programmes. The
Sub-Centers are provided with basic drugs for minor ailments needed for taking care of
essential health needs of men, women and children.54 The Ministry of Health & Family
Welfare is providing 100% Central assistance to all the Sub-Centers in the country since
April 2002 in the form of salary of ANMs and LHVs, rent at the rate of Rs. 3000/- per
annum and contingency at the rate of Rs. 3200/- per annum, in addition to drugs and
equipment kits. The salary of the Male Worker is borne by the State Governments. Under
the Swap Scheme, the Government of India has taken over an additional 39,554 Sub
Centers from State Governments / Union Territories since April, 2002 in lieu of 5,434
Rural Family Welfare Centers transferred to the State Governments / Union Territories.
There are 1, 47,069 sub centers functioning in the country as on March 2010.
Primary Health Centres (PHCs)
PHC is the first contact point between village community and the Medical Officer. The
PHCs were envisaged to provide an integrated curative and preventive health care to the
rural population with emphasis on preventive and promotive aspects of health care. The
PHCs are established and maintained by the State Governments under the Minimum
Needs Programme (MNP)/ Basic Minimum Services (BMS) Programme. As per
minimum requirement, a PHC is to be manned by a Medical Officer supported by 14
paramedical and other staff.56 Under NRHM, there is a provision for two additional Staff
Nurses at PHCs on contract basis. It acts as a referral unit for 6 Sub Centres. It has 4 – 6
beds for patients. The activities of PHC involve curative, preventive, promotive and
Family Welfare Services. There are 23,673 PHCs functioning as on March 2010 in the
country.
Community Health Centres (CHCs)
CHCs are being established and maintained by the State Government under MNP/BMS
programme. As per minimum norms, a CHC is required to be manned by four medical
specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21
paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labour Room
and Laboratory facilities.58 It serves as a referral centre for 4 PHCs and also provides
facilities for obstetric care and specialist consultations. As on March, 2009, there are
4,535 CHCs functioning in the country.
First Referral Units (FRUs)
An existing facility (district hospital, sub-divisional hospital, community health centre
etc.) can be declared a fully operational First Referral Unit (FRU) only if it is equipped to
provide round-the-clock services for Emergency Obstetric and New Born Care, in
addition to all emergencies that any hospital is required to provide. It should be noted that
there are three critical determinants of a facility being declared as a FRU: i) Emergency
Obstetric Care including surgical interventions like Caesarean Sections; ii) New-born
Care; and iii) Blood Storage Facility on a 24-hour basis.
Current Situation of the Human Resources compared to 2005 (Before NRHM)
The launch of the NRHM in 2005 marked a turning point in human resource for health.
The commitments of the centrally-funded scheme to provide the funds needed to close
the human resource gaps between the posts that were sanctioned by the state governments
and the posts that were required to meet the new standards, dramatically changed the
situation. This led to the appointment of almost 1,06,949 more skilled service providers
in the public health system by March 2010, of which 2,460 were specialists, 8,624 were
doctors, 7,692 were AYUSH doctors, 26,993 were nurses, 46,990 were ANMs and
14,990 were paramedical. This was one of the largest increments to the public health
workers in recent times. Also NRHM funds have also enabled the revitalizing of the
community health worker programme in India and the ASHAs over 7, 00,000 signifies a
massive increase in health workers in the country.
When we compare the manpower position of major categories in 2010 with that in 2005,
it is observed that there are significant improvement in terms of the numbers in all the
categories. For instance, the number of ANMs at Sub Centres and PHCs have increased
from 133194 in 2005 to 191457 in 2010 which amounts to an increase of about 43.7%.
Similarly, the Doctors at PHCs have increased from 20308 in 2005 to 25870 in 2010,
which is about 27% increase. Moreover, the specialist doctors at CHCs have increased
from 3550 in 2005 to 6781 in 2010, which implies an appreciable 91% increase in 5 years
of NRHM. By analyzing the state wise picture, it may be observed that the increase
in the ANMs is attributed mainly to significant increase in the states of Andhra Pradesh,
Assam, Goa, Haryana, Jammu & Kashmir, Karnataka, Madhya Pradesh, Maharastra,
Manipur, Mizoram, Nagaland, Orissa, Punjab, Rajastan, Uttarakhand, Uttar Pradesh and
West Bengal. Similarly there is a significant increase in the number of doctors at PHCs in
the states namely Andhra Pradesh, Jammu & Kashmir, Karnataka, Kerala, Madhya
Pradesh, Punjab and Rajasthan.
Analysis
- Rural health care in India faces a crisis unmatched by any other sector of the economy. To mention just one dramatic fact, rural medical practitioners (RMPs), who provide 80% of outpatient care, have no formal qualifications for it. They sometimes lack even a high school diploma.
- In 2005, the central government launched the National Rural Health Mission (NRHM) under which it proposed to increase public expenditure on health as a proportion of the GDP to 3% from 1%. But increased expenditure without appropriate policy reform is unlikely to suffice. Experience to-date inspires little confidence in the ability of the government to turn the expenditures into effective service.
- Rural India consists of approximately 638,000 villages inhabited by more than 740 million individuals. A network of government-owned and -operated sub-centres, primary health centres (PHCs) and community health centres (CHCs) is designed to deliver primary health care to rural folks.
- Sub-centre is the first contact point between the community and the primary health care system. It employs one male and one female health worker, with the latter being an auxiliary nurse midwife (ANM). It is responsible for tasks relating to maternal and child health, nutrition, immunisation, diarrhoea control and communicable diseases.
- Current norms require one sub-centre per 5,000 persons, one PHC per 30,000 people and one CHC per 120,000 people in the plains. Smaller populations qualify for each of these centres in the tribal and hilly areas. Each PHC serves as a referral unit to six sub-centres and each CHC to four PHCs. A PHC has four to six beds and performs curative, preventive and family welfare services.
- Each CHC has four specialists — one each of physician, surgeon, gynaecologist and paediatrician — supported by 21 paramedical and other staff members. It has 30 indoor beds, one operation theatre, X-ray and labour rooms and laboratory facilities. It provides emergency obstetrics care and specialist consultation.
- Despite this elaborate network of facilities, only 20% of those seeking outpatient services and 45% of those seeking indoor treatment avail of public services. While the dilapidated state of infrastructure and poor supply of drugs and equipment are partly to blame, the primary culprit is the rampant employee absenteeism. Nation-wide average absentee rate is 40%.
- The employees are paid by the state, with the local officials having no authority over them. Not surprisingly, many medical officers visit the PHCs infrequently and run parallel private practice in the nearby town. ANMs are frequently unavailable for childbirths even if the mother is willing to come to the PHC. Though PHCs are supposed to be free, most of them informally charge a fee. Under these circumstances, even many among the poor have concluded in favour of private services.
- public health services have done poorly even along the income distribution dimension. According to a 2001 study, the poorest 20% of the population captures only 10% of the public health subsidy compared with 30% by the richest 20%. The share in the subsidy rises monotonically as we move from the bottom 20%. The justification for the government provision of health services on income distribution grounds does not find support in the data.
- To make improvements in the delivery of health services, at least three reforms are urgently required. First, it is time to accept the fact that the government has at best limited capability to deliver health services and that a radical shift in strategy that gives the poor greater opportunity to choose between private and public providers is needed.
- This can be best accomplished by providing the poor cash transfers for out-patient care and insurance for in-patient care. Once this is done, a competitive price must be charged for services provided at public facilities as well. The government should invest in public facilities only in hard to reach regions where private providers may not emerge.
- Second, the government must introduce up to one-year long training courses for practitioners engaged in treating routine illnesses. This would be in line with the National Health Policy 2002, which envisages a role for paramedics along the lines of nurse practitioners in the United States.
- The existing RMPs may be given priority in the provision of such training with the goal being replacement of all RMPs by qualified nurse practitioners.
- Finally, there is urgent need for accelerating the growth of MBBS graduates to replace unqualified “doctors” who operate in both urban and rural areas. Taking into account the evolution of medical colleges and assuming that doctors remain active for 30 years after receiving their degrees, there are at the most 650,000 doctors in India today.
- With a population of 1.1 billion, this implies approximately 1,700 people per doctor. In comparison, there are just 400 people per doctor in the United States and 220 in Israel. Whereas private colleges and institutes in engineering, computer applications and business fields have mushroomed in response to the demand, the same has not happened in the medical field.
- The Indian Medical Council (IMC) zealously controls the entry of new colleges and keeps the existing medical colleges on a short leash. Recently, it threatened to effectively close down as many as six of the eight medical colleges in Bihar because they were in violation of its guidelines on how many senior positions could be left unfilled at any time.
- Given low salaries, colleges face serious difficulties in filling the positions. The result has been extremely slow expansion of capacity in many states. West Bengal has added just two medical colleges since 1969, Rajasthan three since 1965, Punjab three since 1973, Delhi one since 1971 and Bihar two since 1971.
- Only Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu have achieved satisfactory progress. This must change. The IMC perhaps needs to relax its norms and the government needs to make salaries competitive to adequately staff the existing colleges and open new ones.
PUBLIC/PRIVATE PARTNERSHIP IN HEALTH CARE SERVICES IN INDIA
It is widely accepted that the deficiencies in public sector health system can only be overcome by significant reforms. The need for reforms in India’s health sector has been emphasized by successive plan documents since the Eighth Five-Year Plan in 1992, by the 2002 national health policy and by international donor agencies. The World Bank (2001:12,14), which has been catalytic in initiating health sector reforms in many states, categorically emphasized: now is the time to carry out radical experiments in India’s health sector, particularly since the status quo is leading to a dead end. But it is evident that there is no single strategy that would be best option. The proposed reforms are not cheap, but the cost of not reforming is even greater”.
Health Sector Reform (HSR) is defined as a sustained, purposeful change to improve the efficiency, equity and effectiveness of the health sector’. The World Health Organization (1997) defined health sector reform as a sustained process of fundamental change in policy and institutional arrangements of the health sector, usually guided by the government. ..It is designed to improve the functioning and performance of the health sector and ultimately the health status of the people.
Reform strategies include
- Alternative financing (user-fees, health insurance, community financing, private sector investment);
- Institutional management (autonomy to hospitals, monitoring and management by local government agencies, contracting);
- Public sector reforms (civil service reforms, capacity building, productivity improvement); and
- Collaboration with the private sector (public/private partnerships, joint ventures).
Partnership with the private sector has emerged as a new avenue of reforms, in part due to resource constraints in the public sector of governments across the world. There is growing realisation that, given their respective strengths and weaknesses, neither the public sector nor the private sector alone can operate in the best interest of the health system. There is also a growing belief that public and private sectors in health can potentially gain from one another. Involvement of the private sector is, in part, linked to the wider belief that public sector bureaucracies are inefficient and unresponsive and that market mechanisms will promote efficiency and ensure cost effective, good quality services. Another perspective on this debate is linked to the notion that the public sector must reorient its dual role of financing and provision of services because of its increasing inability on both fronts (Mitchell 2000). Under partnerships, public and private sectors can play innovative roles in financing and providing health care services.
While reviewing the health sector in India, the World Bank (2001) and the National Commission on Macroeconomics in Health (2003, 2005) strongly advocated harnessing the private sector s energy and countering its failures by making both public and private sectors more accountable. The Tenth Five-Year Plan (2002-2007) envisioned in detail the need for private sector participation in the delivery of health services.
Collaborating with the private sector and fostering a partnership for providing health services to the underserved sections of the population are particularly critical in the Indian context. Due to the deficiencies in the public sector health systems, the poor in India are forced to seek services from the private sector, often borrowing to pay for them.
India has one of the world s highest levels of private out- of-pocket financing (87 percent estimated in World Bank 2001). Out-of -pocket expense at the point of service use is about 85 percent. Such a mode of financing imposes debilitating effects on the poor. Hospitalisation or chronic illnesses often lead to liquidation of assets or indebtedness. It is estimated that more than 40% of hospitalised people borrow money or sell assets to cover expenses, and 35% of hospitalised Indians fall below the poverty line because of hospital expenses. Out-of-pocket medical costs alone may push 2.2% of the population below poverty line in one year. Approximately 29 percent of the Indian population (almost 300 million people) live below the poverty line and depend on free health services from the public sector. The inequities in the health system are further aggravated by the fact that public spending on health has remained stagnant at around one percent of GDP (0.9%) compared to the global average of 5.5%. Yet even the public subsidy on health does not automatically benefit the poor. The poorest quintile of the population uses only one -tenth of the public (state) subsidies on health care while the richest quintile accesses 34 percent of the subsidies.
Private Sector in India
Over the years the private health sector in India has grown remarkably. At independence the private sector in India had only eight percent of health care facilities (World Bank 2004) but recent estimates indicate that 93% of all hospitals, 64% of beds, 85% of doctors, 80% of outpatients and 57% of inpatients are in the private sector. Contrary to commonly held views, private hospitals are relatively less urban-biased than the public hospitals. Given the overwhelming presence of the private sector in health, various state governments in India have been exploring the option of involving the private sector and creating partnerships with it in order to meet the growing health care needs of the population.
The private sector is not only India’s most unregulated sector but also its most potent untapped sector. Although inequitable, expensive, over-indulgent in clinical procedures and without quality standards or public disclosure of practices, the private sector is perceived to be easily accessible, better managed and more efficient than its public counterpart. It is assumed that collaboration with the private sector in the form of
Public/Private Partnership would improve equity, efficiency, accountability, quality and accessibility of the entire health system. Advocates argue that the public and private sectors can potentially gain from one another in the form of resources, technology, knowledge and skills, management practices, cost efficiency and even a make-over of their respective images (ADBI 2000). Partnerships are expected to ameliorate the resource constraints of the public sector by reducing investments in expensive tertiary care services.
- Public/Private Partnership
There are many ways of defining the terms public and private (Wang 2000). In general, however, the public sector includes organizations or institutions that are financed by state revenue and that function under government budgets or control. The private sector comprises those organizations and individuals working outside the direct control of the state. Broadly the private sector includes all non-state actors, some explicitly seeking profits (for-profit) and others operating on a not-for -profit (NFP) basis. The former are conventionally called private enterprise, the latter non-governmental organizations (NGOs) . In the health sector, for-profit providers may include individual physicians, diagnostic centres, ambulance operators, blood banks, commercial contractors, polyclinics, nursing homes and hospitals of various capacities. They may also include community service extension of industrial establishments, co-operative societies and professional associations. The for -profit private health sector encompasses the most diverse group of practitioners and facilities. But likewise the character of not-for-profit organizations varies in terms of their size, expertise level and geographical spread. NFP services are clustered in charitable clinics or hospitals. Some are established on a financially sustainable basis and are funded from user-charges; most, however, require the support of grants or donations.
Although widely used, the term partnership is difficult to define. Some definitions in the literature are so ambiguous that they cover practically any type of interaction between public and private actors. Yet partnership is often used to describe a range of interorganizational relationships and collaborations. Some of the useful definitions of publicprivate partnership are:
- “,,,,,,means to bring together a set of actors for the common goal of improving the health of a population based on the mutually agreed roles and principles (WHO 1999)
- “……a variety of co-operative arrangements between the government and private sector in delivering public goods or services provides a vehicle for coordinating with non-governmental actor to undertake integrated, comprehensive efforts to meet community needs… to take advantage of the expertise of each partner, so that resources, risks and rewards can be allocated in a way that best meets clearly defined public needs (Axelsson, Bustreo and Harding 2003)
- “….a partnership means that both parties have agreed to work together in implementing a program, and that each party has a clear role and say in how that implementation happens (Blagescu and Young 2005)
- “……a form of agreement [that] entails reciprocal obligations and mutual accountability, voluntary or contractual relationships, the sharing of investment and reputational risks, and joint responsibility for design and execution (World Economic Forum 2005)
Three fundamental themes emerge from these definitions.
First, a relative sense of equality between the partners;
second, there is mutual commitment to agreed objectives; and
third, there is mutual benefit for the stakeholders involved in the partnership.
Partnership is therefore a collaborative effort and reciprocal relationship between two or vmore parties with clear terms and conditions, clearly defined partnership structures, and specified performance indicators for delivery of a set of health services in a stipulated time period. In other words, the core elements of a viable partnership are beneficence (joint gains),autonomy (of each partner), joint- ness (shared decision-making and accountability) and equity (fair returns in proportion to investment and effort).
Challenges in Partnership
While the health system as a whole has common objectives of equity, efficiency, quality and accessibility, public and private providers interpret the contents of these objectives differently. Generally, the motive of the government is to provide health services to all at minimum cost or free; it develops policies and programmes to provide equity of access to such services. From the public sector point of view, there are merits and demerits in collaborating with the private sector.
Not-for-profit organizations have special concern for reaching the poor and the disadvantaged but, in many states, they account for less than one percent of all health facilities. Their sustenance depends on philanthropic donations or external funding. As a result their interventions remain ad hoc, and their up- scalability remains doubtful. But they provide good quality care, need little regulation or oversight from government, are able to attract dedicated staff, and cater to the needs of those otherwise excluded from mainstream health care. Moreover, they are also willing to undertake health care challenges that the for-profit sector is unwilling or unable to take on. Given their non-profit motives and grass-root level presence, NGOs can play useful oversight roles in the system. Their size and flexibility allows them to achieve notable successes where governments have failed.
Opinion is divided on the motives of the (for-profit) private sector, ranging from outright distrust to strong support for close co-operation with it. One extreme view is that the private sector is primarily motivated by money and has no concern for equity or access.
Bennet et al. identified five main problems associated with private-for-profit provision of health services. They are related to the use of illegitimate or unethical means to maximise profit, less concern towards public health goals, lack of interest in sharing clinical information, creating brain drain among public sector health staff, and lack of regulatory control over their practices. Management standards are generally higher in the private (for-profit) sector. The private sector can play an important role in transferring management skills and best practices to the public sector. In India, the formal for-profit sector has the most diverse group of facilities and practitioners. Since it accounts for the largest proportion of services and resources in the health sector, it is argued that future strategies to improve public health should take into account of the strengths of the private sector.
There are also a large number of non-qualified rural medical practitioners in the informal private sector in India. A conservative estimate puts the number of these practitioners at 1.25 million.
Private partner selection and obligations of the Partners
it is possible to suggest that a competitive process of selecting the private sector partner is less effective than an invited or negotiated partnership. A possible explanation may be that, while competing to win a contract, the private partner’s primary concern is to showcase a low cost that would clinch the bid. The public sector managers, on the other hand, are more concerned about satisfying procedural requirements (for internal regulatory systems) than meeting the beneficiaries needs. The tendering process in government invariably chooses the lowest bid. While seemingly economical for the government in the short run, after some time the contractor would expect an upward revision of the tariffs or incentives. In the absence of these, the contractor is unlikely to deliver services in the same level of quality or effectiveness as at the beginning of the contract. Governments may resort to a transparent and competitive process of selecting the private agency to withstand administrative and legal scrutiny. This approach of contracting may be useful in commercial projects but not in the social sector where competitive pricing of services is not the priority; rather, reaching the poor is. Some of the successful partnership projects documented here point to the importance of prior negotiations with the potential partners. In some cases the eligibility conditions were tailor-made or else the prior experience of the agency was used as a basis for choosing the private partner.
Among the core components of any partnership are mutual responsibilities and commitments. In all the partnerships, the public sector is committed to providing the physical infrastructure in the form of building premises, equipment, drugs and supplies, electricity, water connection and in some cases fuel for the ambulance or an equivalent budget item. Otherwise the public sector commits resources by reimbursing expenses incurred or providing grants-in-aid. The responsibilities of the private partners are clearly stated in most of the projects. A common theme of responsibility is to provide uninterrupted services to the target beneficiaries (BPL patients), employment of qualified staff, maintenance and upkeep of physical infrastructure, payment of rents and taxes, and submission of periodic accounts and reports. Some partnership projects prescribe additional responsibilities for the private partners under certain contingencies. For example, the Rajiv Gandhi super -speciality hospital should be ready to provide free services during natural calamities; Shamlaji hospital should cater to medico legal cases and treat accident and trauma cases. All the partnership projects are expected to provide services under national programmes, including immunization and family planning. Private partners are allowed to extend the services beyond the scope of the partnership agreement.
There is no pattern to indicate whether the public/private partnership as a policy option was guided by donor agencies or due to compulsions of resource constraints or due to competitive bureaucracy. However, public/ private partnership seems to have been prompted by visionary personalities from the bureaucracy and from civil society. Analysis suggests that states that experimented with partnership ideas before formalising a policy seem to be more successful compared to those that promulgated a formal policy without experimentation. Policy pronouncements by government alone are not sufficient for public/private partnerships to succeed. Visionary leadership, social entrepreneurship and relationships based on trust between the stakeholders are equally important for successful partnerships.
Capacity of private partners and public sector officials towards managing the partnerships is yet to be fully developed. Public sector managers may perceive the new initiative as a burdensome task, requiring them not only to placate their subordinates but also to seek better performance from their private partners. This is a daunting task. Private partners, who are known for their informal and flexible systems and organizational processes, are uncomfortable with the rigid organizational and managerial processes and procedures of the public sector. Bureaucracy is yet to become conversant in the principles of New Public Management.
Designing partnership (contract) agreements requires sufficient capacity-building measures but central government leadership may not be ideal for achieving this aim. States could create regional resource centres to develop these capacities locally. The approach towards pricing of tariffs for services (both in block grants or in case- based reimbursements) is based only on competitive tendering process rather than on a standard calculation of competitive rates. Similarly the payment system is mired in red tape that impedes successful partnerships.
Policy innovations such as public/private partnerships are, of course, highly contextual. Partnership with the private sector is not a substitute for the provision of health services by the public sector. Also, public- private partnership initiatives cannot be uniform across all the regions or suitable under all kinds of political and administrative dispensations. While private partnership is an administrative decision, an obvious but important point is that it must enjoy political and community support. In states where the private sector is prevalent, partnership initiatives could be an alternative, not necessarily, because of competitive efficiency but to prevent further immiseration of the poor and the deprived sections of society. There has to be a clear rationale for partnering with the private sector. It is important to understand not only what services are to be provided under private partnership but also to understand the basis on which such decisions are made.
Any policy initiatives to strengthen the flagging public sector health services in India would be welcome. But a government that fails to deliver quality social services due to lack of basic administrative capacity would not be able to contract either clinical or nonclinical services. The first step must be to improve basic administrative systems.
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