POLICY BRIEF – BLURRING OF BOUNDARIES: PUBLIC PRIVATE

PARTNERSHIPS IN HEALTH SERVICES IN INDIA 1

Summary: With Globalisation there is a need to break away from isolation to

cooperation, there is hence a need for new partnership between different sectors at all
levels of government in societies. But a careful treading is required with greater
emphasis on mechanisms and institutions to bring transparency in these partnerships.

Introduction:

1- History

There has been a rapid change at the global level regarding the role of the market and
state in the healthcare sector. Alma Ata (1978) gave precedence to the state and
highlighted the link between development and health. With rise in neo liberalism this
stance shifted and by late 80s global institutions like WHO endorsed the need for
partnerships between the state and the market for financing, provisioning and
research in health services. With emergence of multilateral organisation like UNDP,
World Bank etc the Public Private Partnership (PPPs) gained greater legitimacy and
resulted in complexity of the design.

The main theme that emerged was advocating of free market ideology and
minimalisation of state’s control over its health services.

2- Evolution of Partnerships

The NGO’s initially had the task of community mobilisation and education, only a very
small amount of private practitioners or health institutions were seen within the
country. It was only during the 90s that the PPPS (Public Private Partnerships) gained
momentum with the government recognising the private players as equal partners.

3- Characterisation &Distribution of PPPs

There is huge difference in the types of PPPs that exist within the country but primarily
most of these can be described as contracting in and contracting out of services. At
the secondary level these are restricted to contracting out of non clinical services like
laundry, diet, drug etc. The PPPS in these models can be described and limited to just
a few actors but that is not the case in others where a lot of actors and intermediaries
act.

4- Lessons from PPPs in RNTCP(Revised National Tuberculosis

Programme) & RCH(Reproductive & Child Health)

The RNTCP & the RCH Programmes have shown immense plurality and complexity
wherein there has been the involvement of multilateral actors and the responsibilities
are shared across various sectors. The partnership in the TB Programme primarily
emphasised on the detection of the disease. Further research showed that
collaboration was present at the NGO and private practitioners but was seen absent at
the private hospital level; in addition intermediaries like the local medical associations
brought together public and private providers to sustain the partnership.

Importance of Coordinator

1 Review of the article that appeared in the Economic & Political Weekly, January 26th 2008
a- This partnership had its constraints in the functioning because though the
detection and treatment was with the private practitioners but the referral was an
integral part of the programme which resulted in decrement of the efficacy of this
programme.

b- Social Franchising

This is being seen as a very attractive health policy especially for the states that have
a very weak network of public services. It involves a combination of contracting out
with an extensive system of public subsidies. This PPP model incorporated franchising
shops, clinics and centres by giving them brand name and hence a mix of franchising,
marketing, and contracting out its reach in the several rural district. The problem still
remains is that this model does not target the poorest population for which subsidies
and discount prices have to be built into the system.

At the secondary level there is the model for delivery of RCH services through PPPs.
The objective was to provide transportation to those who couldn’t afford it. A MOU
has been signed between the private provider and the health officer wherein the
private practitioners have been hired, and private hospitals work. The government
gives them their fee and further reimbursements.

1- Constraints on Building Partnership

Non availability of players in the market, the framing and content of MOUs, the
administrative and organisational capacity of the system to define roles and regulate
these partnerships

• Political patronage leads to discrepancy in competition.

• MOUs inadequate in demarcating the responsibilities and rules that govern the
same.
• No serious regulations or penalty on non compliance of contracts
• No third party Institutional mechanism to independently arbitrate breach of
MOUs by either party
• The government provides the NGO with infrastructure while the NGO provides
resources and personnel. Hence there is a recurring spending on human and
other resources which the NGO has to incur.
• The government spells the MOU hence little power to the NGO for it to contest
or negotiate the terms and condition.
• PPPs are seen as cost effective but there is an urgent need to deliberate on the
parameters for cost effectiveness.

Conclusion

PPPS were seen as the combination of the best in both sectors and blurring of the
weaknesses but off late due to poor institutional mechanisms, unregulated laws and
government apathy has resulted in much debate on the way this model works.