8.

PUBLIC PRIVATE PARTNERSHIP (PPP) FOR

ESSENTIAL HEALTH SERVICES
An innovative approach for optimum and efficient use of public and private resources
*Md.Azam Ali MCcmmh
Health care is the most important basic right and as such the world is still committed
towards achieving “Health for All” the unattained goal of the ALMA-ATA Declaration.
However, for HFA the struggle to remove the prevailing inequalities and creating
supportive provisions for the majority and particularly to the poor to date continued to be
difficult and remains as the major challenge for the world health.
This paper intends to share in brief a new vision called “Public Private Partnership
(PPP) for Essential Health Care Services (ESP)” developed and being implemented in
Bangladesh which aims at increased accessibility of services in general and particularly
of the poor.
Like in many developing countries Bangladesh intends to increase accessibility of
health care for the poor by increasing allocation of resources for public sector and
maintaining free care provisions for most services in government clinics and hospitals.
However, in spite of the generous development grants still there exists huge resource
gap for the sector compared with the need. Due to this, permission for public providers
to supplement income through private practice and weak accountability, the public health
care system remains deficient with its credibility and availability of essential service still
is in accessible for the majority of the disadvantaged population. Side by side, the rapid
growth of the urban focussed high tech for-profit private sector further contributing
towards widening the inequalities. Studies showed that people who can afford to pay
make more use of free services than the poor. An analysis of public expenditure
revealed that there are significant differences in the distribution of public expending by
geographical region, inequalities in the process of obtaining care both through high user
payment and longer waiting times for the poorest groups and males /boys using non
reproductive primary care more than women/girls.
The private sector of Bangladesh comprises of formal profit and non-profit (NGO &
trusts) institutions and huge informal sector consists of private practitioners with or
without proper training and accreditation (who sometime are referred as Rural Medical
Practitioners or RMPs). Utilization pattern of these different forms of private providers
varies with background of the clients. While there is an increasing trend of using formal
private sector in urban area in rural areas the RMPs are still the first point of primary
care for the majority. In most cases these RMPs are source of readily available
cheap/poor quality medicines and they act as brokers for the organized profit driven
private sector. NGOs and some trust organizations are offering parallel services which is
known to be effective but their coverage is patchy, concentrated in urban cities and not
supportive towards building a comprehensive national health care delivery system.
However there exist mix feeling about both the potential and danger of this fast growing
private sector. Accountability of the private sector, weak /ineffective regulation of the
sector by the Government and absence of any clear vision of how best the private sector
can play the role.
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*Sr. National Adviser, Nicare/British Council, (a DFID TA to Bangladesh HPSR)
In the above context with three distinct elements ; a) Community –based Health
Scheme b) Funding and Commissioning Partnership, and c) Health Providers
Partnership, PPP this experimental intervention of Bangladesh HPSR working towards
developing sustainable continuum care provision through community empowerment and
participation. Together with available pubic sector resources, community funds are being
mobilized and placed under decentralized management and community control.
Services charges introduced to protect the limited public resource being wasted and
ear-marked only for the poor. Through Participatory Poverty assessment poor are
identified and exemption mechanism worked out. Different stakeholder groups including
the poor and women are mobilized to raise their voices and take part in the management
net work. NGOs and local government institutions are playing important role in
mobilizing the community and building solidarity so that the cost for caring the poor can
be subsidized.
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Factors Constraining Private Physician

Practices
- Not able to meet the felt needs of the community
- Cannot involve himself in the community health services – in
preventive and promotive services.
- Not able to keep up with the changing trend of technology.
- Inability of the patients from the lower socio-economic group
requiring access to a private physician.
- Access to low-cost investigations and drugs.
- High level competition
- Lack of good medical insurance and reimbursement system.
- Lack of adequate facilities and equipment
- Cost of establishment of clinics
- Urban based clinics are becoming speciality / super-speciality
clinics
- Lack of funds and lack of specialized training
- Not keeping abreast of the latest technological knowledge.
- Lack of proper records and information system
- Lack of supportive services in clinical lab, X-ray, advance
investigations, inability to manage complications.
- Lack of standardized treatment protocols.
- No quality control to distinguish efficient, ethical practioners
from “quacks”
- Increased pressure from the pharmaceutical and medical
equipment industry
- Lack of efficient networking with superspeciality facilities for
the remote practicing physicians
- Majority do not take up emergency and critical care for fear of
mortality.
In future, it would be better to establish partnership clinics.