Summing Up

Acknowledgments  Rapporteuring team  Presenters  Participants

 Definition of PPPs  Ideological debate: Relation between market and state.  Dominance of new public management in HSR

 Key operative terms in looking at PPPs: Accountability, Effectiveness and Regulation Why PPPs (Dr Raman): to assist in furthering state’s goals  REDUCE OUT OF POCKET EXPENSES – EQUITY  REACH OUT INACCESSIBLE AREAS/ GROUPS – ACCESSIBILITY  MORE SOPHISTICATED / TECHNOLOGY INTENSE CARE – QUALITY  COST EFFECTIVE – EFFICIENCY  CONTROL IRRATIONAL BEHAVIOUR – REGULATION  DEPLOY MORE FOCUSED RESOURCES - INVESTMENT

 Conceptual framework for looking at PPPs: one of them proposed was “role-authority and power”  Concerns related to PPPs: Lack of clarity between commercialization and PPPs. Delineation between public and the private- lumping of private players. Values would be different for NGOs (not for-profit) and the for-profit private sector. Unequal partners- is it partnership or engagement with the private sector or just a business relationship  Privatisation /PPPs  Plurality of models  Lack of evidence

 What is available is descriptive and case studies - no impact assessment - no evaluation of impact on equity and access at both micro and macro levels.  Much of the debates are ideologically driven and polarized: either market driven or skeptical about commercialization  The issues plaguing each of the sectors: Public- corruption, governance, accountability, lack of evidence-based reform. Private- no regulation, gross violations, malpractice, Conflicts of interest

Crucial requirements  Monitoring and evaluation of contracts  Independent regulatory system for oversight  Explicit, transparent and adequate governance mechanisms  Social safety measures for protection of the vulnerable sub-sections

 No universal approach to the issue will work.  Impact on public health sector needs to be studied  Nature of contracts needs to be studied

 Role of NGOs as private players: Running services, capacity building, infrastructure Sustainability?? Challenges to scaling-up: NGOs working within the public health system Vs NGOs working in isolation (islands of excellence) Role of leadership at the level of NGOs and State Driven by International Donor agendas: focus on vertical programs and state disinvestment or withdrawal from services (in the context of a history of international ‘economic’ reforms).

 Role of Co-operatives Strengths: network, reach Limitations: lack of professionalism, poor HR management Public Co-operativePrivate

 PPPs under NRHM State is flush with funds but low absorption capacity Hasty planning, no market survey PPPs seen as panacea, transferring all responsibilities Directive rather than dialogue Changing guidelines, wandering bureaucrats No mutual trust, political interference Need for capacity building of state Does the State know what it is getting into? Lack of monitoring Limited reach, limited scope Cash assistance rather than service provision Insufficient compensation

Regulation  Monitoring system (are the objectives really met at the field level?), regulation/accreditation and accountability for both public and private players  Raising “performance: equity, quality and efficiency”  Can it lead to compromised autonomy and ability to innovate?  Transparency enhancement to ensure engagement for public purposes  Contract management & Clarity of ownership  Costing  Gray areas in the area of Provision, Financing as well as Governance & Stewardship  Role of legislation but also enforcement  Role of the private purchasers of care (IRDA)

Gaps ………….  Available evidence: Descriptive- case specific, Few studies under NRHM throwing up issues related to the top-down approach.  Lack of information among researchers, policy makers and beneficiaries about the schemes.  Need for studies looking at impact on access and equity rather than micro analysis (especially before we scale up ‘successful’ schemes.  Need to look at impact on the public health services (shortage of HRH, brain drain)  Compare certain PPPs like Chiranjeevi (bunched payment for purchase of care) and Yashasvini (insurance model) to understand impact of these especially over the long term  Contracting is one of the most common forms of partnership but requires further investigation (Bhabha)

PPPs: elephant in the room and blind men/women  Is the elephant itself also blind  Is the elephant providing free rides to the people, paid rides or discounted rides to the local hospital for sight restoration procedures  Are these rides a precursor to being partially or fully trampled subsequently or to a stage where neither the people are blind nor rides are needed.

Thank You