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Blurring of Boundaries: Public-Private Partnerships in Health Services in India

This paper traces the evolution, structure and characteristics of public-private partnerships in healthcare over the last six decades. It argues that these partnerships have broken down the traditional boundaries between the market and the state, leading to the emergence of multiple actors with multiple roles and newer institutional arrangements that have redefined their role, power and authority. The fragmentation of role and authority has serious consequences for comprehensiveness, governance and accountability of health services.

SPECIAL ARTICLEjanuary 26, 2008 Economic & Political Weekly62Blurring of Boundaries: Public-PrivatePartnerships in Health Services in IndiaRama V Baru, Madhurima NundyThis paper traces the evolution, structure and characteristics of public-private partnerships in healthcare over the last six decades. It argues that these partnerships have broken down the traditional boundaries between the market and the state, leading to the emergence of multiple actors with multiple roles and newer institutional arrangements that have redefined their role, power and authority. The fragmentation of role and authority has serious consequences for comprehensiveness, governance and accountabilityof healthservices. To address emerging threats to health, new forms of action are needed. There is a clean need to break through traditional boundaries within government sector, between governmental and non-governmental organisation, and between public and private sectors. Cooperation is essential; this requires the creation of new partnerships for health, on an equal footing, between the different sectors at all levels of govern-ance in society [WHO 1997].1 IntroductionThe statement by the World Health Organisation (WHO) in the late 1990s represents a paradigm shift at the global level regarding the role of the market and state in health. The Alma Ata declaration on primary healthcare in 1978 gave centrality to the state and highlighted the link between development and health. This discourse became peripheral at the global and national levels in the context of the world economic crisis and the ascendance of neoliberalism. This ideological shift that occurred during the 1980s and 1990s impacted on global institutions like theWHO that hitherto had played a normative role in formulating health policies across countries. Gradually, theWHO endorsed the need for partnerships between the state and market for financing, provisioning and research in health services. Pharmaceutical companies played a significant role in the technical bodies of the disease control programmes of the WHO through their funding of research and supply of drugs at the global level.1During this period, public-private partnerships(PPPs) gained greater legitimacy with increase in the number of partners and complexity of designs. Multiple actors in global partnerships included multilateral organisations like the World Bank, United Nations Development Programme (UNDP), United Nations Children’s Fund (UNICEF); pharmaceutical companies like Merck, Smith-Kline Beecham; American foundations like the Melinda and Bill Gates, Carter, Clinton, etc and bilaterals like the United States Agency for International Development (USAID), Depart-ment for International Development (DFID), European Commis-sion (EC); international non-governmental organisations (NGOs) and church-based organisations. Some of the major global partnerships are the Global Alliance for Vaccines and Immunisa-tion (GAVI), Global Alliance for the Elimination for Lymphatic Filariasis (GAELF), Global Alliance for Tuberculosis(TB) Drug Development, Stop TB Initiative, Global Alliance to Eliminate Leprosy; Global Elimination of Blindness and Trachoma, Global Polio Eradication Initiative, Multilateral Initiative for Malaria, Joint United Nations Programme on HIV/AIDS(UNAIDS)/Industry Drug Access Initiative [Reich 2002].This is a modified version of a paper presented at the Research Committee on Poverty, Social Policy and Social Welfare conference 19 of the International Sociological Association on ‘Social Policy in a Globalising World: Developing a North-South Dialogue’, University of Florence, Italy, September 6-8, 2007. We would like to thank Tuba I Agartan of Bogazici University, Turkey for her detailed comments. We would like to acknowledge the Monitoring Health Sector Policies in South Asia Project, Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi for the travel grant to participate at the conference. Rama V Baru (rbaru2002@yahoo.co.uk) and Madhurima Nundy (madhurima.nundy@gmail.com) are at the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi.
SPECIAL ARTICLEEconomic & Political Weekly january 26, 200863The global endorsement by theWHO and other multilateral organisations of PPPs had its influence on the national and local levels of planning and implementation of health policy. It strengthened and supported the free market ideology that advocated a reduced role for governments in the economy and social sectors by breaking down the traditional boundaries between the state and market. Although there has been a history of collaborations between the public and private sectors in the Indian health services, it has undergone significant changes in recent times, especially with the growth ofPPPs.2 EvolutionofPartnerships An analysis of the collaborations between the state and private sector in health is seen prominently in the national health programmes (NHPs). Most of these collaborations were in the nature of a supportive role for community mobilisation and education with limited service provisioning.2 From the first plan onwards, the government had elicited support and cooperation of “for-profit” and “non-profit” sectors in the malaria and family planning programmes. Initially the government sought the support of NGOs at the primary level for community mobilisation and education. But later these collabo-rations extended to the for-profit sector and several other NHPs. Table 1 summarises the nature of public-private collaborations and partnerships in the health sector over the last six decades and it shows that majority of these have occurred in the family welfare programme. Private and non-governmental collabora-tions have largely been for creating awareness and demand for family planning services through community mobilisation. Only a small proportion of private practitioners and clinics were involved in providing contraception and abortion services. The state provided subsidies in the form of devices and monetary incentives to these sectors for providing services.3 It is during the last two decades that the concept of PPPs has been introduced into the health programmes. The distinction between thePPPs of the 1990s and the earlier forms of collabora-tion is that the former conceptualises both partners as equal and is arbitrated through a formal memorandum of understanding (MOU) while in the latter the role of non-state players was peripheral to the programme. During the mid-1980s the idea of PPPs got introduced into several disease control and the repro-duction and child health(RCH) programmes (Table 1) that received external funding, mainly from the World Bank, which provided the rationale and guidelines for initiating and sustain-ing partnerships. The design of these partnerships was informed by the new public management (NPM) practices and techniques that emphasised a shift from traditional administration to public management informed by notions of economic efficiency of markets [Larbi: 1999]. As Larbi argues, A common feature of countries going down the NPM route has been the experience of economic and fiscal crises, which triggered the quest for efficiency and for ways to cut the cost of delivering public services. The crisis of the welfare state led to questions about the role and in-stitutional character of the state. In the case of most developing coun-tries, reforms in public administration and management have been driven more by external pressures and have taken place in the context of structural adjustment programmes (ibid).Table 1: Summary of Public-Private Collaborations Five-Year Plans: 1951-2007Five-Year Plans Components and levels of services renderedFirst Plan (1951-56) Setting up of antenatal and postnatal clinics by NGOs. Licensing of private nursing homes for maternal and child health services. The government of India enter intoan agreement with the UNICEF and the WHO to carry out a countrywide BCG programme. Non-official organisations encouraged to establish and run tuberculosis institutions and governments to give them building and maintenance grants provided these institutions are run on non-profit basis. Voluntary organisations to be stimulated to set up, with state aid, after-care colonies at suitable places in association with tuberculosis institutions. It should be possible adequately to provide drugs through a combination of private enterprise.Second and Third Plan Government subsidies and grants were given to states, local authorities,(1956-61 and 1961-66) NGOs and scientific institutions for family planning clinics and research relating to demographic issues. Maternity and child welfare services provided by the primary health centres are supplemented by services provided by welfare extension projects and by voluntary organisations. A large number of voluntary organisations and social workers in anti-leprosy work to be associated in the leprosy programme.Fourth and Fifth Plan NGOs to integrate family planning as part of their other health services (1969-74 and 1974-79) that they extended to the community, distribution of contraceptives and education. In urban areas it was proposed that private practitioners provide advice, distribute supplies and undertake sterilisations. Financial support from government to private practitioners and NGOs. In order to create a sense of partnership with government efforts voluntary contributions to be encouraged in the malaria programme.Sixth Plan (1980-84) Encourage private medicalprofessional and non-governmental agencies for increased investment. Government offers organised, logistical, financial and technical support to voluntary agencies active in the health field. Encourage the participation of voluntary agencies through financial support in leprosy. Financial assistance to be provided to voluntary organisations which provide medical care facilities at the village level through doctors employed on part-time basis.Seventh Plan (1985-90) Voluntary organisations and local bodies encouraged to undertake responsibility for family welfare and primary healthcare services NGOs involved in the extension education and motivation in FPP. Scheme for assisting private nursing homes for family planning work continued. Increased emphasis laid on MCH activities by supporting NGOs, village health committees, and women’s organisations. Priority would also be assigned to enlist community participation and the aid of voluntary organisations in the leprosy programme. Organised blood-bank and blood transfusion services will be further developed with the active participation of the centre, the states and voluntary organisations.Eighth Plan (1992-97) Encourage private initiatives, private hospitals at secondary and tertiaryand Ninth Plan level.(1997-2002) Role of NGOs, social marketing in RCH programmes. Some contracting out of primary level services.Tenth Plan (2002 – 07) Increased involvement of voluntary and private organisations, self-help groups and social marketing organisation in improving access to healthcare. Contracting in and out of clinical and non-clinical services. NGO sector to support the government in handling RCH services like providing transport for emergency obstetric care for which funds would be devolved at the village level and PPPs introduced in several states. Preparation of IEC material and social marketing of contraceptives has been handed over to the NGO sector.Source: GOI (various years), Five Year Plans, Planning Commission.3 Characteristics and Distribution of PPPsIn this section we examine the characteristics and distribution of PPPs in different states, across types and levels of care in the Indian health services over the last decade. We base our analysis on descriptive studies, evaluation reports and primary interviews by delineating the role of actors involved; their status within these partnerships; the distribution of power and authority between these partners.

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SPECIAL ARTICLEjanuary 26, 2008 Economic & Political Weekly70Appendix Table: Forms and Design of PPPs in Health in India Type States Actors in PPPs Services Included under PPP Design of PPPI Contracting in Rajasthan, Jaipur Tertiaryteaching hospital, Drug store Hospital provides physical space, electricity, water and computers for the drug and out private contractors store to the private operator CT Scan/MRI services Services given to a private agency. Agency is given a monthly rent and they have to provide 20 per cent free services Himachal Pradesh, Karnataka, Public hospitals at Cleaning and maintenance Cleaning and maintenance of hospitals contractedto Sulabh International in some Orissa, Punjab, Uttaranchal secondary and tertiary of building, security, waste states, dietary services in Bombay municipal hospitals and some government and Tripura, Maharashtra, level, private agencies management, scavenging, hospitals either contracted in or out of the hospital West Bengal laundry, dietary services, etc Gujarat National disease control IEC services for malaria control Information education and communication (IEC) budget fromvarious programme (State pharmaceutical companies is pooled together on a common basis and the Malaria Control Society), agencies hired by the private sector are allocated the money for development of private agencies IEC material through a special sanction. Tamil Nadu, Theni district Non-governmental Emergency ambulance This scheme is self-supporting through the collection of user charges. The organisation services government supports the scheme only by supplying the vehicles. The NGO recruits the drivers, trains the staff, maintains the vehicles, operates the programme and reports to the government. It bears the entire operating cost of the project including communications, equipment and medicine, and publicising the service in the villages, particularly the telephone number of the ambulance service. However, the project is not self-sustaining as the revenue collection is lesser than anticipated. Contracting in Widespread in 439 districts NGOs, government Basket of RCH services, capacity The MNGO (mother NGO) and SNGO (service NGO) Schemes are being and out RCH programme building of field NGOs (FNGOs), implemented by NGOs for population stabilisation and RCH. The MNGOs involve conducting community needs smaller NGOs called FNGOs (field NGOs) in the allocated districts. assessment (CNA), liaison, networking and coordination with state and district health services, PRIs and other NGOs; monitoring the performance and progress of FNGOs and documentation of best practices, advocacy and awareness generation. The SNGOs provide an integrated package of clinical and non- clinical services directly to the community. Andhra Pradesh, Delhi Charitable trust, private Tuberculosis (i) In Andhra, the trust hospital acts as a coordinator, intermediary and supervisor practitioners, nursing between the government and private medical practitioners (PMPs). The PMPs homes, TB programme refer patients suspected of having TB to the hospital or to any of the 30 specified neighbourhood DOTS centres operated by PMPs.The patients pay the fees to the PMPs. (ii) In Delhi, the Delhi Medical Association acts as the intermediary between the government and private practitioners (PPs) and provides training to the PPs to improve rates of case detection.10“Tangible inputs like building infrastructure, equipment, etc, is necessary for creating the con-ditions that are necessary for personnel to carry out their roles effectively. However, even if the tangibles are in place the intangible dimension, which includes the behaviour of personnel with the patient is shaped both by organisational and societal factors”, R V Baru and Chris Mary Kur-ien, ‘Towards an Expanded Conceptualisation of Quality in Public Health Services’, unpublished paper.ReferencesAnnigeri, Vinod B, Lizann Prosser, Jack Reynolds and Raghu Roy (2004): An Assessment of Public-Private Opportunities in India, The United States Agency for International Development, India.Arora, V K, K Lonnroth and R Sarin (2004): ‘Improved Case Detection of Tuberculosis through a Public-Private Partnership’ inThe Indian Journal of Chest Diseases and Allied Sciences, 46, pp 133-36.Baru, R V and Chris Mary Kurien (2002): ‘Towards an Expanded Conceptualisation of Quality in Public Health Services’, unpublished paper, Centre of Social Medicine and Community Health.Baru, R V and M Nundy (2006): ‘Health PPPs in India: Stepping Stones for Improving Women’s Repro-ductive Health Care?’ paper presented at UNU Conference on Improving Women’s Health in India, December 3-5, Bonn, Germany.Bennett and Mills (1998): ‘Government Capacity to Contract: Health Sector Experience and Lessons’ in Public Administration and Development, 18, pp 307-26.Bhat, R, D Huntington and S Maheshwari (2007): ‘Public-Private Partnership, Contracting Arrange-ments and Managerial Capacity to Strengthen RCH Programme Implementation: Lessons and Implications from Interventions in India’, work-ing paper no 2007-05-02, Indian Institute of Man-agement, Ahmedabad.Dewan, Puneet K, S S Lal, Knut Lonnroth, Fraser Wares, Mukund Uplekar, Suvanand Sahu, Re-uben Granich, Lakhbir Singh Chauhan (2006): ‘Improving Tuberculosis Control through Public-Private Collaboration in India: Literature Review’ inBritish Medical Journal, 332; pp 574-78.Futures Group (2005): ‘Contracting Out Health Facilities in India’, prepared for Policy Division of the Ministry of Health and Family Welfare’ GOI, ITAP, IFPS II Technical Assistance Project.Government of India (1951; 1956; 1961; 1966, 1980; 1985; 1992; 1997; 2002):Five Year Plans, Planning Commission, New Delhi.– (2006): ‘Draft Report on Recommendation of Task Force on Public-Private Partnership for the 11th Plan’, Planning Commission, New Delhi. – (2007): ‘Policy Reform Options Database (PROD) for Effective Health Sector Reforms’, accessed from http://www.hsprodindia.nic.in/Kumar, M K A, P K Dewan, P K J Nair, T R Frieden, S Sahu, F Wares, K Laserson, C Wells, R Granich, L S Chauhan (2005): ‘Improved Tuberculosis Case Detection through Public-Private Partnership and Laboratory-Based Surveillance, Kannur District, Kerala, India, 2001-02’ inInternational Journal of Tuberculosis Lung Disease, 9(8), pp 870-76.Larbi, George A (1999): ‘The New Public Management Approach and Crisis States’, Discussion Paper No 112, United Nations Research Institute for Social Development, New York.Prakash, G and A Singh (2006): ‘Outsourcing of Healthcare Services in Rajasthan: An Exploratory Study’, paper presented at the Global Competi-tiveness for Outsourcing: Implications for Servic-es and Manufacturing, IIM Bangalore, July 13-15. Qadeer, I and S Reddy (2006): ‘Medical Care in the Shadow of PPP’ inSocial Scientist, Vol 34, Nos 9-10, pp 4-20.Reddy, Sanjay (2001): ‘Strategies of Social Provision: Key Design Issues’ in Germano M Mwabu, Cecilia Ugaz, Gordon White (eds),Social Provision in Low-Income Countries: New Patterns and Emerg-ing Trends, OUP, New York, pp 104-22.Reich, Michael R (2002): Public-Private Partnerships for Public Health, Harvard Series on Population and International Health, Harvard Centre for Population and Development Studies, Cambridge, Massachusetts.Uplekar, M, Vikram Pathania and Mario Raviglione (2001): ‘Private Practitioners and Public Health: Weak Links in Tuberculosis Control’ inThe Lancet; 358, pp 912-16.Venkataraman, A and J W Bjorkman (2006): ‘Public-Private Partnership in the Provision of Health Care Services to the Poor’, Research Study sup-ported by Indo-Dutch Programme on Alternatives in Development (IDPAD).WHO (1997): Jakarta Declaration on Health, WHO, Geneva.(continued)
SPECIAL ARTICLEEconomic & Political Weekly january 26, 200871 Assam Government RCH General services, Involves contracting a trust hospital - Marwari Maternity Hospital (MMH) to programme, RCH services provide services in eight low-income municipal wards of the city, having a total trust hospital population of 2-2.5 lakh. The state government pays the MMH for providing outreach and referral services, in the identified areas. In addition, vaccines and contraceptives are provided free to MMH. MMH is covering 14 outreach sites in these areas. It is mainly providing RCH services but the outreach team includes a doctor and they can also treat simple ailments or refer patients to the hospital. Gujarat, Karnataka NGOs Management of PHCs in rural areas/ (i) Government of Gujarat has provided grants to an NGO in Gujarat for managing one urban health services PHC and three CHCs.The NGO provides rural health,medical services and manages the public health institutions. The NGO can accept employees from the district panchayat on deputation. It can also employ its own personnel by following the recruitment resolution of either the government or the district panchayat. (ii) Management of primary health centres in two districts was contracted out by the Government of Karnataka to an NGO in 1996 to serve the tribal community in the hilly areas. 90 per cent of the cost is borne by the government and 10 per cent by the trust. It has full responsibility for providing all personnel at the PHC and the health sub-centres within its jurisdiction; maintenance of all the assets at the PHC. The agency ensures adequate stocks of essential drugs at all times and supplies them free of cost to the patients. Uttaranchal, West Bengal NGOs Mobile health services in villages (i) In Uttaranchal, government partners with an autonomous public agency and shares the funding with it. An NGO is provided with the funds, supplies and they have to implement the programme of providing primary level services and diagnostics in rural hilly areas (ii) An NGO in West Bengal is funded by the government of West Bengal and three other international funders to provide outreach primary level health services to 81 villages. Delhi NGO, municipal Management of urban (i) In Delhi as contractual partners, an NGO and MCD each has fixed responsibilities corporation health services and provides a share of resources as agreed in the partnership contract. The NGO is responsible for organising and implementing services in the project area, while the MCD is responsible for monitoring the project. The MCD provides building, furniture, medicines and equipment, while the NGO provides maintenance of the building, water and electricity charges, management of staff and medicine. Andhra Pradesh NGOs,state health and Urban Slum Health Project (ii) The Urban Slum Health Care Project – the Andhra Pradesh ministry of health and family welfare ministry family welfare contracts NGOs to manage health centres in the slums of Adilabad. The basic objectives of the project are to increase the availability and utilisation of health and family welfare services, to build an effective referral system, to implement national health programmes, and to increase health awareness and better health-seeking behaviour among slum dwellers, thus reducing morbidity and mortality among women and children. Gujarat (Chiranjivi experiment Private gynaecologists Emergency obstetric care, transport, Federation of gynaecologists andobstetricians, empanelled private providers. in five selected districts) in nursing homes at caesarean section, forceps delivery, secondary level ultra sonography, anaesthesia, blood, IEC to popularise the scheme Rural Uttar Pradesh Private sector at Sterilisation and IUD services, pre and post Government reimburses and district societies implement the programme through secondarylevel operative medicines,follow up,transportation theprivateinstitutions. and reporting to the district society Madhya Pradesh, Bhopal Rogi Kalyan Samiti (RKS) or RKS to manage a secondary level RKS functions as an NGO and not a government agency.It may impose user charges. patient welfare committee government hospital It may also raise funds additionally through donations,loans from financial formed as a society.Its institutions,grants from government as well as other donor agencies. The funds members are from local received are available to be spent by the executive committee constituted by the PRIs, NGOs,local elected RKS/HMS.Private organisations could be contracted out for provision of the super representatives and specialty care at a rate fixed by the RKS.Through RKS,the hospital has also been government officials. able to provide free services to patients below the poverty line. Bihar Secondary level hospitals Immunisation, manage HIV/AIDS, State, district hospital and charitable trust (part of Londonbased organisation). voluntary counselling, testing, DOTS, leprosy, RCH services Andhra Pradesh, Karnataka Secondary and tertiary Hospitalisation coverage (i) Government premiums for initial years, in the case of Yeshasvini scheme, level private hospitals network of hospitals provides free surgeries to insured farmers of cooperative societies that is administered through a TPA (ii) Hospitalisation and accident benefit by the department of health and family welfare for rural poor by locating a network of nursing homes in each area. Karnataka Chamarajinagar Tertiary level district Tele-medicine and tele-health project State government provides space, equipment, staff and VSAT connectivity, cost district hospital hospital of free care to BPL patients; ISRO provides tele-link and satellite connectivity; trust hospital trains staff and manages the unit and gives free tele-consultation to patients BPL, nominal charges from other patients. Karnataka, Raichur district Tertiary level public Provide all services and some Management contract to a corporate entity to operate and maintain the hospital. hospital percentage to BPL. II Social Bihar Primary level (preventive Janani scheme (mostlycontraceptives Mix of social franchising, marketing, outsourcing and external funding. franchising and curative) and basic health services). III Social marketing several states NGOs Promotion and sale of contraceptives SIFPSA, HLL, PSI, Hindustan Latex and Family Planning Promotion Trust. with subsidies for the products. Sources: Compiled and adapted from: (1) Annigeri et al 2004; (2) Futures Group, 2005; (3) GOI (2006); (4) http://www.hsprodindia.nic.in/ (5) A Venkataraman and J W Bjorkman (2006). As cited in Baru and Nundy (2006), ‘Health PPPs in India: Stepping Stones for Improving Women’s Reproductive Health Care?’ paper presented at UNU Conference on Improving Women’s Health in India, December 3-5, 2006, Bonn, Germany.Appendix Table:(Continued) Type States Actors in PPPs Services Included under PPP Design of PPP

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