1 by Deepak Mili Integrated Mphil/ PhD Tata Institute of Social Sciences, Mumbai Public Private Partnership in Health: An Understanding of PPPs in Primary Health Care in Arunachal Pradesh

2 Background Arunachal Pradesh is a vast hilly area spread over sq.km. in the north eastern part of India. Absence of the private healthcare sector, especially in remote and rural areas. The Government of India is interested in exploring ways to partner with the private sector to improve health outcomes for the poor.

3 Rationale of the Study: For people living in interior rural areas, lacking economic and social mobility, primary health is the only available form of health care. Locational disadvantage of sub centres, PHCs, CHCs due to mountainous terrain and sparsely distributed tribal population in forest and hilly regions.. Active participation of the Civil Society and the community in improving Health Care delivery system.

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5 Objectives To find out reasons for involvement of NGOs through PPP in running PHC’s in Arunachal Pradesh. To understand the process of implementation of PPP in the context of roles and responsibilities of various stake holders in running PHC’s in Arunachal Pradesh.

Sampling Design: The universe of the study was comprised of the people living in and around the catchments area of the six districts of Arunachal Pradesh. These six districts are as follows: 1.Deed Neelam PHC, Lower Subansiri District. 2.Gensi PHC, West Siang District 3.Lumla PHC, Tawang District 4.Nacho PHC, Upper Subansiri District 5.Sille PHC, East Siang District 6.Thrizino PHC, West Kameng District Sampling Technique: Convenience sampling 6

The numbers of PHCs that were handed over to different NGOs are as follows: Karuna Trust, Karnataka : 9 PHCs Voluntary Health Association of India : 5 PHCs Prayaas, New Delhi : 1 PHC Future Generation, Arunachal Pradesh : 1 PHC 7

Method of data collection: Interview schedules were used for people living in the catchments areas of the PHCs and semi structured interviews were used with key informants at State, district, Sub division and Circle level. The key informants included: District Medical Officer of the Six Districts District RCH officer of the Six Districts Medical Officer of the PHC Sub divisional Officer /Circle Officer/ Gram Panchayat member of the area where PHC is located. 8

PPP in Operation: For operating the PHCs the government provides 90% of the funds of medication and staff salaries. (Rs.28, 34,172/ annum) The PHCs are responsible for providing the following services: 24 hours Emergency/Casualty Services. OPD service for six days per week as per the timings specified by the State Government bed inpatient facility. 24 hrs labour room and emergency Obstetrics facility. Minor Operation Theatre Facility 24 hrs Ambulance Facility Make available essential medicines as per the details at Schedule B of the MOU. The Agency would be encouraged to keep in stock such additional medicines as are found necessary after assessing the field situation. Participation in and implementation of National Programs of Health & Family Welfare including the National Rural Health Mission. 9

Monitoring Structure A PHC management committee was constituted at the PHC level comprising representatives of the Agency, DMO, District RCH Officer, DC or his nominee (not below the level of Circle Officer) and not more than three representatives from the Anchal Samitis in the Area. The local MLA of the area was a permanent Special Invitee to the PHC Management Committee. The Committee is scheduled to meet at least once, every two months and is responsible for guiding/monitoring the project. At the State level, a Steering Committee chaired by the Commissioner & Secretary (Health) along with suitable representation from all stake holders including the Agencies, Central Government and other State Government Departments is formed. This State level steering committee is supposed to meet at least once, every three months. The model that is adopted in running PHCs in Arunachal Pradesh is contracting out model under which the whole PHC is handed over to NGOs. 10

11 The Reality of Partnership in Arunachal Pradesh- SWOT Analysis Strengths: Availability of at least one doctor in the six PHC areas were the study was conducted where previously no doctors were available on duty when the government was running the PHC. Availability of medicines in the PHCs presently being run by the NGOs and the indent of the medicine is made by the pharmacist in consultation with the Medical Officer (MO) of the PHC according to the needs of the PHC. Increase responsiveness of government health facilities to local needs through community involvement by formation of PHC Management Committee in each district which comprised of NGO staff, Member of village panchayat and district health authority. Increased competition by effectively ending government’s monopoly on the provision of public services and introducing increased competition, contracting of PHC can drive down costs and provide an incentive for providers to explore innovative methods of service delivery.

12 Weaknesses: Insufficient incentives as the present remuneration that was given to the PHC staff was same as that of government and no additional incentive was given to those posted in remote areas as a result a number of post varying from LHV to MO were lying vacant in the PHCs where the study was conducted. PPP is unequal as the Public sector is both judge and party and the NGO’s who have taken over the PHC do not have much say in it. Sole dependence on the Project Manager who with his dynamic personality and commitment was the driving force behind the success of the programme till now. Such personality dependence of the programme is a major weakness and it may turn into threat anytime if such person happens to leave. The successful performance of the NGOs in PPP has created some prejudice in the minds of govt. officials who are being blamed for their lack of results. This has led to resistance and non cooperation from health officials to support the programme. Lack of support from other departments of district administration in implementing the programme. The NGOs has not shown enough commitment of resources to recruit full requirement of manpower and there are still vacancies in some PHC.

13 Opportunities: Indigenous system of medicine including herbal, traditional practices should also be taken into consideration; indigenous health practitioners should be recognized and financially supported by the government. (MOHFW –NHP 2002). The paramedical staffs posted at distant and geographically difficult terrains can be provided additional increments or incentives in order to attract them to serve in the rural and remote areas. These paramedical staffs can be recruited from the Paramedical Institute located in the East Siang district of Arunachal Pradesh. Currently government budgets are focused on inputs. Money flows to health services on the basis of organ grams, seniority, size of establishment and previous expenditure patterns. Well designed PPP programmes can allocate government funding on the basis of population needs, demand for services, quality of service provided and health outcomes achieved. International funding to PPP projects are very high. This can be utilized to channelize more funds to the project.

14 Threats: Inadequate education and awareness on PPP among the community leading to inadequate support and acceptance from the community. The posting of medical and paramedical staff at the PHCs and SCs should be based on the established norms rather than any other influencing factors or political pressure or nepotism. Accountability is an issue as the present MO’s appointed by the NGO are accountable to the Project Manager of the NGO and are not accountable to the State Government. The PHC Management committee has been formed to review but it seems to be of not much help as far as accountability is concerned. Risk sharing is a crucial issue as currently the state government is offering 90 % of the whole cost of this programme and the respective NGOs are pooling in 10% which may encourage even some inefficient NGO’s to undertake the programme. Lack of sustainability is another threat as NGOs is running the PHC and tomorrow if the NGO leaves the project and goes away the community is presently not in a position to take up the responsibility.

15 Recommendations: The model requires an NGO that has the financial resources to complement the government’s contributions. It is also essential that the NGO have full hiring and firing of staff. As most of the PHCs were located in the far flung areas and there was not even phone connection available in some of the PHC so in PHC’s where phone connection is not available WLL phone should be provided to them which will be of great help for them. Unavailability of electricity supply in the PHCs. One of the PHC has set up solar plates if other PHCs can attempt to installs solar plates it will help a lot in running ILR and other important gadgets.

16 Contd. As there are few villages which are not yet accessed by the present staff it will be a good idea to set up mobile clinics in places like weekly markets where these villagers from nearby areas come for marketing and can also avail health facilities. Introduction of Health Mela like the one conducted in East Kameng district in other districts also. Lack of sustainability is another issue if the NGOs maintaining the PHC decide not to continue the project and leave; the community is presently not in a position to take up the responsibility.

Thank You for your attention. 17