P UBLIC P RIVATE P ARTNERSHIP IN H EALTH C ARE IN I NDIA Presenter: Dr. Reshma Moderator: Dr. Subodh S Gupta

F RAMEWORK Concept of public private partnership Need of public private partnership Objectives of PPP Principles of PPP Models of PPP Existing PPP in Health sector Challenges faced in operationalization

C ONCEPT OF P UBLIC P RIVATE P ARTNERSHIP “ Public” would define Government or organizations functioning under State budgets, “Private ” would be Profit/Non-profit/Voluntary sector and “Partnership ” would mean a collaborative effort and reciprocal relationship between two parties Public-Private Partnerships (PPP ) are collaborative efforts, between private and public sectors, with identified partnership structures, shared objectives, and specified performance indicators for delivery of health services

N EED OF PUBLIC PRIVATE PARTNERSHIP Source: National Health Accounts Report of MOHFW/GOI. (With Provisional Estimates from to )

Source: Pearson M, Impact and Expenditure Review, Part II Policy issues. DFID, 2002 N EED OF PUBLIC PRIVATE PARTNERSHIP

OBJECTIVES OF PUBLIC PRIVATE PARTNERSHIPS Improving quality, accessibility, availability, acceptability and efficiency Exchange of skills and expertise between the public and private sector Mobilization of additional resources. Strengthening existing health system Widening the range of services and number of services providers. Universal coverage and equity for primary health care

PRINCIPLES OF PPP Set up common goals and objectives Joint decision-making process Relative equality between partners Accountability and responsibility set out for each partner Understanding the strengths and weakness of the partners among themselves A high level of trust and confidence Benefits to both the stakeholders

PRINCIPLES OF PPP Monitoring and evaluation: (i) by government departments authorized to do so, based on a standardized scale (i) by independent agencies/regulators based on a standardized scale (ii) by department or independent agencies, based on the simple criteria of pass and fail (iii) by department or independent agencies, based on the feedback received from the beneficiaries.

SELECTION OF SERVICE PROVIDERS IN PPP Competitive Bidding Competitive Negotiation Swiss Challenge Approach

P UBLIC -P RIVATE -P ARTNERSHIP M ODELS Franchising Contracting out Contracting-in Social marketing Joint ventures Voucher schemes Involving professional associations Build, operate and transfer Running mobile health units Community based health insurance

F RANCHISING Franchise is a business model where the franchiser grants exclusive rights to franchisees to conduct business in a prescribed manner over a specified period The franchisees contribute resources of their own to set up a clinic and pay membership to franchiser

S OCIAL M ARKETING Application of marketing techniques to achieve a social objective. Associated with expanding access to contraceptives and medicine The trend is to increase the available products, including oral rehydration solution, IFA tablets and other health products to make marketing more self-sustaining.

Example: Janani in Bihar Social marketing and social franchise program in Bihar It combines social marketing with a clinic-based service delivery program and a franchisee program through which doctors in rural areas provide low-cost services. Family planning and comprehensive abortion care through Surya Clinics. Titli centres sells condoms, pills and pregnancy test kit Supplies contraceptives to both rural and urban pharmacies and shops. F RANCHISING AND SOCIAL MARKETING

C ONTRACTING O UT Contracting out refers to situation in which private providers receive a budget to provide services and manage a government health unit. Identify those government health clinics that need to be contracted out Vacancies for a long period, high absenteeism, and consistent low performance on all RCH indicators could be the critical criteria

E XAMPLE OF CONTRACTING OUT 1. Govt. of Karnataka, Narayana Hrudalaya hospital in Bangalore and Indian Space Research Organization initiated project called ‘Karnataka Integrated Tele-medicine and Tele- health Project’, which is an on- line health-care initiatives in Karnataka. Tele-diagnosis and consultation in cardiac care and specialist care. Free diagnosis, medicines and treatment for BPL patients

E XAMPLE OF CONTRACTING OUT 2. SMS Hospital has contracted out the installation, operation and maintenance of CT- scan and MRI services to a private agency Free services to 20% of the patients belonging to the poor socio-economic categories

C ONTRACTING IN Hiring of one or more agencies or individuals to provide services. Example : Hiring of medical specialists for certain days of the week in PHC or CHC.

J OINT V ENTURE C OMPANIES Joint venture companies are companies launched with equity participation of government and private sector. Joint venture companies, in most cases have not succeeded due to lack of understanding and trust between partners

J OINT V ENTURE C OMPANIES Example: The Rajiv Gandhi Super-specialty Hospital in Raichur Karnataka is a joint venture of Govt. of Karnataka and Apollo hospitals Group, with financial support from OPEC (Organization of Petroleum Exporting Countries)

V OUCHER S YSTEM A voucher is a document that can be exchanged for defined services as a token of payment Package can be bought, used when required and ensures privacy for the client. Example: Chiranjeevi Yojna in Gujarat

B UILD, OPERATE AND TRANSFER BOT models are highly successful in infrastructure development sector Financing of projects by government, subsidized land at prime locations These models are useful to establish large hospitals and ensure quality services at reasonable rates to poor people

R UNNING MOBILE HEALTH UNITS Vans go to identified central points on fixed days and provide primary health services to a cluster of villages. Vehicle, medical equipments, medicine will be provided by govt. and primary health care services will be provided by NGOs 4 Mobile medical unit for Gadchiroli, 3 each for Gondia and Nandurbar and one each for remaining 30 districts in the state. Bihar adopted the scheme under the name “Arogya Rath” & in Madhya Pradesh under the name “ Deen Dayal Chalit Aspatal Yojana”

C OMMUNITY BASED HEALTH INSURANCE Government pays health insurance premium for families below poverty line. These families in turn are insured against expenses on health and hospitalization, up to a certain amount. Community members pay a minimum insurance premium per month and get insured against certain level of health expenditure Community based schemes ensure that local needs and expectations of people are met

C OMMUNITY BASED HEALTH INSURANCE Example: Rashtriya Swasthya Bima Yojna (RSBY) Provide protection to BPL households Beneficiaries are entitled to get up to Rs. 30,000/- per year Beneficiaries need to pay only Rs. 30/- as registration fee while Central and State Government pays premium to the insurer selected by State Government on basis of a competitive bidding.

C OMMUNITY BASED HEALTH INSURANCE Example: Karuna Trust in collaboration with National Health Insurance Company and Government of Karnataka Improve access and utilization of health services

I NVOLVING PROFESSIONAL ASSOCIATIONS Professional associations such as Indian Medical Association, Gynaecologists federation, nurses associations Technical skills and expertise to provide advice on matters such as setting standard protocols, quality assurance systems and accreditation Extended help in launching new programmes such as Vande Mataram Scheme

EXISTING PPP SCENARIO IN INDIA Partnership between the government and the profit sector Partnership between the government and the non profit sector

P ARTNERSHIP BETWEEN THE GOVERNMENT AND THE PROFIT SECTOR Government of Andhra Pradesh has initiated Arogya Raksha Scheme in collaboration with New India Assurance Company and with private clinics. It is an insurance scheme fully funded by government. It provides hospitalization benefits and personal accident benefits to citizens below the poverty line The government paid an insurance premium of Rs. 75 per family to insurance company

P ARTNERSHIP BETWEEN THE GOVERNMENT AND THE NON PROFIT SECTOR Example1: Municipal Corporation of Delhi and Arpana Trust have developed a partnership to provide comprehensive health services to the urban poor in Delhi’s Molarbund resettlement colony Arpana Trust runs a health center primarily for women and children Arpana Trust is responsible for organizing and implementing services in the project area, while MCD is responsible for monitoring the project

Public/private DOTS model established on pilot basis in Hyderabad at Mahavir Trust Hospital Mahavir Trust Hospital acts as a coordinator and intermediary between govt. and private medical practitioners PMPs refer TB suspected patient to hospital Govt. benefit as DOTS medicine are not wasted Mahavir Trust Hospital also benefited as their service cure patient P ARTNERSHIP BETWEEN THE GOVERNMENT AND THE NON PROFIT SECTOR

C ASE STUDIES : C HIRANJEEVI Y OJNA SCHEME Launched in Gujarat 2005 Aim : Improve access of poor families (BPL) to institutional delivery Form of partnership : Voucher scheme to involve private providers in delivering maternity care Reasons for contracting: High maternal mortality, low institutional delivery, involving large groups of private practitioners Financing: NRHM and state budget

C ASE STUDIES : C HIRANJEEVI Y OJNA SCHEME CONT.. Implementation problems: Inadequate awareness among private providers about the scheme benefits Shortage of specialists Uniform service package impedes handling of high-risk cases Monitoring quality of Care Challenges: With no system of cross checking BPL, the scheme now runs the risk of processing bogus and fraudulent claims. According to facility survey conducted under RCH II, at least two of the districts do not have essential obstetric care services. None of the private providers were aware of the fact that one pre-delivery visit and an investigation is part of the Chiranjeevi package.

C ASE STUDIES : M OTHER NGO SCHEME Mother nongovernmental organization scheme was initiated as a centrally sponsored scheme within RCH I. Under RCH II, the scheme was decentralized with greater involvement of states in selection and monitoring. Goal : Provision of RCH care to underserved regions. Form of partnership : Contracting out to nongovernmental organizations to work in underserved areas

C ASE STUDIES : M OTHER NGO SCHEME Reasons for contracting: Limited capacity of government to deal with smaller NGOs, increasing the capacity of these organizations to expand RCH services in the community Funding: Government of India under NRHM Target group: Women of reproductive age

C ASE STUDIES : M OTHER NGO SCHEME o Implementation problems: Capacity of stakeholders a major constraint Procedural delay in Selection and disbursement of funds Insufficient credibility and trust among stakeholders Inadequate monitoring Implementation of mother NGO scheme is based on national guidelines, with no consideration of local capacity

C ASE STUDIES : A NDHRA P RADESH URBAN HEALTH CENTRE SCHEME Government of Andhra Pradesh initiated the scheme in 2000 Goal: Provide basic primary health care and family welfare services to urban poor living in slums Form of partnership: Contracting out urban health centres to nongovernmental organizations Reasons for contracting: Expanding primary health care services in urban areas through NGO Financing: Initially funded by Indian Population Programme VIII and then taken up by the State

C ASE STUDIES : A NDHRA P RADESH URBAN HEALTH CENTRE SCHEME CONT.. Implementation problems: No incentive for NGOs to participate Inadequate incentive for urban health centre staffs Delay in disbursement of funds Urban health centres not equipped to handle changing scenario

C HALLENGES FACED IN OPERATIONALIZATION True partnerships in sense of equality amongst partners, mutual commitment to goals, shared decision making and risk taking are rare. Absence of representation of the beneficiary in the process Lack of effective governance mechanisms for accountability Non transparent mechanisms Lack of Institutional Capacity to design, contract, monitor PPPs Payment Delay Local political interference

HLEG RECOMMENDATION TO ENSURE SUCCESSFUL PPP Adequately synchronize the public and private sectors by plugging existing gaps in health systems policy documents Enable government functionaries to structure, regulate and monitor PPPs Adherence of PPPs to national health programme protocols

R EFERENCES Report of the PPP sub-group on social sector. Government of India. Planning Commission Accessed at URL: Draft report on recommendation of task force on public private partnership for the 11th plan. Accessed at URL: Public Private Partnership in health sector. Uttarakhand – A success story. Edited by- Sumit Barua.Uttarakhand PPP cell. Government of Uttarakhand, Deaprtment of Planning. Published by: Government of India - Department of Economic Affairs, Ministry of Finance in collaboration with Asian Development Bank Institute WHO. Public–Private Partnerships: Managing contracting arrangements to strengthen the Reproductive and Child Health Programme in India. Lessons and implications from three case studies. Ahmedabad: WHO; 2007 High Level Expert Group Report on Universal Health Coverage for India. New Delhi: Planning Commission of India; 2011 Health Finance Indicators. National Health Profile Accessed at URL: Care for health market innovation. Janani Available from: The Indian express. Chiranjeevi scheme failed to deliver: CAG report Available from: NRHM. Mobile medical unit. Operational Guidelines for NGO. National Rural Health Mission, State Health Society, Mumbai. Available from: nrhm/guidemmu.pdf Rashtriya Swasthya Bima Yojana. Health and Family Welfare Department Available from: