Year : 2009 | Volume
: 2 | Issue : 2 | Page : 46--52
Primary health care and public-private partnership: An indian perspective
Ranabir Pal1, Shrayan Pal2,
1 Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences (SMIMS) and Central Referral Hospital (CRH), 5th Mile, Tadong, Gangtok, Sikkim - 737 102, India
2 Medical Student (MBBS) , Sikkim-Manipal Institute of Medical Sciences (SMIMS) and Central Referral Hospital (CRH), 5th Mile, Tadong, Gangtok, Sikkim - 737 102, India
Department of Community Medicine, Sikkim-Manipal Institute of Medical Sciences (SMIMS) and Central Referral Hospital (CRH), 5th Mile, Tadong, Gangtok, Sikkim - 737 102
Background: In the new millennium, the progress and success of primary health care (PHC) in India has been delegated to and nurtured in the hands of growing number of «SQ»for-profit«SQ» and «SQ»not-for-profit«SQ» public-private partnerships along with secondary and tertiary care. This article tries to analyze the adequacy and quality of the ever increasing public-private partnership (PPP) in PHC in India. Objective: To assess time trends and overall patterns of public-private partnership in PHC in India. Materials and Methods: We conducted a literature search for data sources through an extensive search in indexed literature and website-based population survey reports; 13 states with public-private partnerships working on PHC were identified. A broad criterion to define both «SQ»for-profit«SQ» and «SQ»not-for-profit«SQ» PPPs was taken. Outcome variables were success of PPPs in PHC implementation. Results: The study critically reviewed PPPs in the light of their services in the PHC segment and significant policy perspectives by an in depth analysis with operational issues in the management and functioning of the schemes. In the health sector PPPs in India, as social entities, pool the best features of the two merging authorities of Government and private sector. They have already shown their potential. Conclusions: In India, PHC, PPP have shown accountability to the people in India. The time has come to explore this to the fullest extent.
|How to cite this article:|
Pal R, Pal S. Primary health care and public-private partnership: An indian perspective.Ann Trop Med Public Health 2009;2:46-52
|How to cite this URL:|
Pal R, Pal S. Primary health care and public-private partnership: An indian perspective. Ann Trop Med Public Health [serial online] 2009 [cited 2019 Sep 21 ];2:46-52
Available from: http://www.atmph.org/text.asp?2009/2/2/46/64269
In 1978, the World Health Organization (WHO) and the United Nations Children Education Fund (UNICEF) studied a history of global health rights in Alma Ata, USSR. In the Alma Ata Declaration, 134 countries subscribed to the goal of "Health for All by Year 2000". They affirmed WHO's broad definition of health as "a state of complete physical, mental, and social well being". To approach health for all, the world's nations, together with WHO, UNICEF, and major funding organizations, pledged to work towards meeting people's basic health needs through a comprehensive, remarkably progressive approach called "primary health care" (PHC). PHC includes promotion of proper nutrition and an adequate supply of safe water; basic sanitation; maternal and child care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; education concerning prevailing health problems and the methods of preventing and controlling them; and appropriate treatment for common diseases and injuries. The declaration stresses the need for a comprehensive strategy that not only provides basic health services for all, but also addresses the pervasive underlying social, economic and political causes of poor health that links health to a strongly participatory strategy known as people-centered development . India's commitment to provide PHC to the masses dates back to the recommendations of the Bhore Committee in 1946. India's rededication to the PHC approach in 1978, implicit in the signing of the Alma Ata declaration of HFA 2000 AD redefined this approach for provision of health care to the masses. Considering the predominance of the rural population, great emphasis was placed on the development of infrastructure techniques and manpower for service delivery mainly in rural areas - rightly so!
The transition from agrarian to urban based economics necessitates a reorientation of the national polices and priorities. Urban slums are deprived human settlements, which are demographically, economically and environmentally vulnerable. It must be realized that the average figures of urban areas hide the stark reality of the urban deprived slums. No clear cut data on slum population was available. The health problems of the urban poor are related to a complex web of causation. The provision of PHC, therefore, cannot be compartmentalized, but has to be provided as a part of overall comprehensive urban slum development. 
The concept of Public-Private Partnership (PPP) has been popular in the last decade of the last millennium and has now become an increasingly popular option in health care delivery system in India. Historically many such projects have been implemented in the PHC segment in different states of India with different levels of perspectives. The National Rural Health Mission (NRHM: 2005-2012) from the Government of India planned to set up PPPs at different levels of health care as key partners to success in implementation. NRHM has contemplated that involving the private sector as part of the RCH initiative will provide more effective health care delivery system.  The number of private sector institutions and dependence on them has been increasing over the years; the private sector now provides more than 70% of curative care. In Uttar Pradesh, of the women who seek care for reproductive health problem, 71 % seek care from the private sector. 
India has, since independence, developed a huge health care infrastructure in both public and private sector (including voluntary organizations).
Apart from the for-profit private sector for health care, the non-governmental organization (NGO) and voluntary sector have also been providing health care to the community. More recently, PPPs have been attempted to involve the private sector in delivery of national health programs and in drug development. Some of the initiatives in India include improving access to PHC services.  There are a few important issues in PPP, like choice of model for shared investments and operating expenses and time frame for contract, defining a formula for shared revenues for a fair contract; estimating volume growth is tricky. There are many sources of revenue,: we can charge the client (utility, service provider or citizens) or generate from advertisements-building, transaction slips. Legal and policy frameworks which encourage PPP are authentication and security of private partner transactions, design of service level contract (obligations on all partners) and ability to enforce as PPP model can create another type of monopoly. Conditions that foster reform are strong political driver and seasoned civil servant executor- In high risk projects (innovations) presence of both is ideal, political support is required to end monopoly provision of services by departments and tackle vested interests and civic pressure plays a limited role in initiating the project.
However, civic pressure is critical in preventing a rollback of reform. Media plays an important role in minimizing resistance from vested interests and in motivating the staff enabling policy framework and legal environment that encourages civil servants to be entrepreneurial. 
This article tries to analyze the progress and success of PHC in the new millennium when, due to different reasons, not only secondary and tertiary care but also PHC is delegated to and nurtured in the hands of growing number of 'for-profit' and 'not-for-profit' PPPs.
Materials and Methods
Retrospective study design based on systematic review of primary health care was appraised on an extensive collection of studies, including meeting presentations and personal communications, from different sources in which PPPs were reported.
Literature search for data sources was done through an extensive search in indexed literatures and website- based population survey reports. Thirteen states were identified where public-private partnerships are working on primary health care found in thirty potentially relevant articles.
All published articles in indexed journals available from various institutional libraries of India and websites on PPPs were included in this study. Studies have also been identified by searching Pubmed-entrez and abstracts from scientific meetings. Reviews of citations and reference lists helped identify additional eligible studies. The search terms included PPPs and PHC. Sources were contacted (wherever possible) for further information on survey data not readily available in the public domain. Manual searches were conducted from review articles and previous meta-analyses. We also contacted authors for additional information or translations from languages other than English.
We developed a broad criterion to define both 'for-profit' and 'not-for-profit' PPPs.
Retrospective study design based on systematic review of PPP on PHC was done by an extensive array of data. We attempted the comprehensive, annotated assembly of survey results from different sources; published surveys and field studies in which PPP on PHC were reported, meeting presentations, personal communication on recent surveys not included in previous analyses. Sources were contacted for further information on survey data not readily available in the public domain.
Standard nomenclatures based on information provided in the publications by the global experts have been used.
Success of PPPs in implementation of PHC
In an ideal PPP, in the health sector, the newly created entity pools the best features of the two merging authorities. Various state governments in India have been experimenting partnerships with the private sector to reach the poor and underserved sections of the population. PPPs are increasingly seen as an important mechanism for improving PHC. Located in rural and urban areas, the health services studied included mobile services, general curative care, maternal and child health services, community health financing activities, health promotion activities. We examined how the roles of a common shared vision, strong governance, and effective management influence a partnership's ability to achieve its objectives.
The findings, based on both qualitative and quantitative analyses, underscore the importance of membership organizations' perceived benefits and cost of participation and management capabilities to the partnership's progress toward a vision. In India, several private partnership initiatives are currently under implementation in the Manipal Group of Health Care enterprises including Sikkim-Manipal University of Health, Medical and Technological Sciences, Gangtok, Sikkim.
In the array of these forms of partnerships, there is little evidence to indicate the relative merits of one form of private partnership over the others. There are four types of operational issues in the management and policy perspectives on PPP. A brief overview of them is needed before any specific analysis. 'Contracting' (contracting 'out' and 'in') was the predominant model of private partnership. Other two forms of partnerships i.e. social franchising and social marketing; were also studied in the research.  The private sector was represented in the form of individual physicians, commercial contractors, large private and corporate super-specialty hospitals and NGOs.
Some of the partnerships deal with simple contracts (diet, laundry, cleaning, etc) while others are more complex involving many stakeholders (Yeshasvini, a community based self financed health insurance scheme). In almost all partnerships, the principal public partner is the department of health and family welfare, either state or central, directly or through health facility level committees. In terms of the monetary value, the least valued contract was in providing dietary services at a rate of Rs. 27 per meal for about 30 meals a day (Bhagajatin hospital, Kolkata). The oldest partnership (since 1996) is the adoption and management of primary health centers in Karnataka by Karuna Trust. The Chiranjeevi scheme (engaging private doctors for deliveries) in Gujarat is the newest of the initiatives (since Dec. 2005). Most of the projects are specific to a geographical region while some benefit an entire state (Yeshasvini scheme). 
The role of individuals in the initiation and success of PPP is very crucial. For example, in the case of Arpana Swasthya Kendra, the project director of Arpana Swasthya Kendra worked hard to convince the political leaders and administrative heads of the Municipal Corporation of Delhi, for approval for a proposal to hand over the Corporation health centre to the NGO under an agreement. In the case of Yeshasvini scheme, founder and director of Narayana Hrudayalaya, Dr. Devi Shetty played a critical role in setting up the Karnataka Integrated Telemedicine and Tele-health project. There are of course other personalities involved in the project too. In the case of adoption and management of the primary health centers in Karnataka, role of Dr. Sudharshan from Karuna Trust was crucial. Similarly initiatives of people like Col. Pant (Uttaranchal mobile health clinic), Dr. KJR Murthy (Mahavir Trust Hospital), Mr. M.A. Wohab (Boat based mobile health services in Sunderbans), and Dr. Haren Joshi (Shamlaji Hospital, Gujarat) have inspired partnership initiatives. Chamrajanagar, a predominantly tribal inhabited district, had only primary care facilities in the district hospital. 
In the case of Karnataka and West Bengal, the state level policy on public-private partnership was framed after launching few pilot projects. In the case of Tamil Nadu, Rajasthan, and Gujarat, the state policy towards the private sector partnership seem to have been introduced without any prior experimentation. Tamil Nadu is one such state where private sector involvement in health services was encouraged for a long time, especially encouraging the industrial houses. It would be fair to say that as of now the policy is virtually ineffective. The state of Andhra Pradesh, had a positive engagement in health sector reforms, does not have any private sector partnership initiatives of significance in the state currently. Government pays 75% of the running cost and the rest is to be mobilized by the NGO. Karnataka is one of the first states to begin this scheme for involving NGOs and private medical colleges in running primary health centers. Karuna Trust was the first NGO to be handed over a primary health center when in 1996 the Gumballi PHC in Chamarajanagar district was handed over to us after 10 years of work in that area on Leprosy, Tuberculosis and Epilepsy [Table 1]. 
From the analysis of the cases, it is clear that the government grants under PPPs are invariably directed towards primary care services. This repudiates the claim in some quarters that partnership with private sector would divert government resources towards tertiary care services. The argument that private partnership is a route towards privatization does not hold much truth even in the primary care services as the private sector cannot sustain operations at these locations without government grants. Therefore government role is indispensable. The critical issue in PPP all over the world, is the timely release of grant/reimbursement to the private partner. Core to this issue is the procedural requirement in getting the funds released.
Across the world, partnership with the private sector has emerged as a new avenue of reforms, in part resulting from resource constraints for the public sector by various governments.  However, there is a growing realization that given their respective strengths and weaknesses, neither the public sector nor the private sector alone would be at the best interest of the health system.  Involvement of the private sector is, in part, linked to a wider belief that public sector bureaucracies are inefficient and unresponsive and that market mechanisms will promote efficiency and ensure cost effective, good quality services The World Bank and the National Commission on Macroeconomics in Health strongly advocate harnessing the private sector's energy and counter its failures, and to make both public and private sectors more accountable. ,
Governments in India presuppose that partnerships could help in ameliorating the problem of poor health services delivery at two levels: a) to improve delivery mechanisms and, b) to increase mobilization of resources for healthcare. Other presumed benefits of partnerships include improvement in quality of services, reduced cost of care either due to competition or through economies of scale, re directing the public resources to other areas, reduction in duplication of services, adoption of best practices, targeted services to the poor, and improve self regulation and accountability.  The government is ultimately responsible for the delivery of services. If there are any deficiencies from the private sector the responsibility for dereliction of services fall on the government health functionaries. Inadequacy in the PPP in the PHC delivery system is a product of failures in a range of quality measures -- structural (lack of equipment and essential drugs), process failings (non-use of the national case management algorithm and lack of a protocol of systematic supervision of health workers). Efforts to improve the quality in the study setting and similar locales in less developed countries (LDC) should focus not only on resource-intensive structural improvements, but also on cheap, cost-effective measures that address actual delivery of services (process), especially the proper use of national guidelines for case management, and meaningful supervision. Since a majority of the partnership projects has to do with primary care services, it is presumed that quality issues in specific terms may not have been envisaged. Opportunities exist for PPP in a competitive environment. Private institutions may deliver their services at a profit but at reduced prices, subsidized or even fully paid for by the government. Similarly, the government may make available products, such as drugs, for free or at significantly low costs to private providers who serve the poor. There is no shortage of ideas to improve the quality of health care delivery, while ensuring access for everyone regardless of income. However, only with a global commitment to improving PHC can the present health crisis faced by developing countries be effectively addressed. Primary health care is a new approach to health care, which integrates at the community level all the factors required for improving the health status of the population available to all people at the first level of health care. In a radical departure from the traditional health care system, it is conceived as an integral part of the country's plan for socio-economic development. 
The National Health Policy 2002 states: "In principle, this policy welcomes the participation of the private sector in all areas of health activities - primary, secondary or tertiary." The policy includes not just private sector companies but also NGOs, community-based organizations (CBOs), Panchayati Raj institutions (PRIs) and other forms of civil society. 
Private partnership is an administrative decision. An obvious but important point is that it must enjoy political and community support. It is important to understand not only what services are to be provided under private partnership, but also the basis on which such decisions are made. We explored the implications of this research for future evaluations of public-private primary health partnerships. One of the core components of PPP is mutual responsibility/ commitment. All the partnership projects are expected to provide services under national programs, including immunization, family planning, etc. All the partnership agreements should have clear operational guidelines and specific performance indicators for the private partners.
In India, deficiencies of the public health system could be overcome by reforms in the health sector. One of the important reform strategies is collaborating with the private sector in the form of PPP. Partnership with the private sector is 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, under immense economic duress. In the health sector, the PPP as a social entity pools the best features of the two merging authorities of government and private sectors which have already shown their potential of accountability the people of India. The time has come to explore this to the fullest extent to promote health of the common mass in our country.
However, there are not many reports on PPP in PHC. Inter observer bias is possible and hence critical comments on data presented here are welcome. 
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