PUBLIC PRIVATE PARTNERSHIP

By: Ms. Priyanka Bansal

Msc. Nursing- I year
Rufaida College of nursing.
 INTRODUCTION
 
 It is widely accepted that the deficiencies in public sector health system
can only be Overcome by significant reforms. The need for reforms in
India s health sector has been Emphasized by successive plan documents
since the Eighth Five-Year Plan .

 But it is evident that there is no single strategy that would be best option.
“The proposed reforms are not cheap, but the cost of not reforming is
even greater”.

 Partnership with the private sector has emerged as a new avenue of

reforms, in part due to resource constraints in the public sector of
governments across the world.
 There is growing realization that, given their respective strengths and
weaknesses, neither the public sector nor the private sector alone can
operate in the best interest of the health system. There is also a growing
belief that public and private sectors in health can potentially gain from
one another.
 DEFINITIONS
 “,,,,,,means to bring together a set of actors for the
common goal of improving the health of a population
based on the mutually agreed roles and principles (WHO
1999)

 A partnership means that both parties have agreed to

work together in implementing a program, and that each
party has a clear role and say in how that
implementation happens (Blagescu and Young 2005)

 A form of agreement [that] entails reciprocal obligations

and mutual accountability, voluntary or contractual
relationships, the sharing of investment and reputational
risks, and joint responsibility for design and execution
 ORIGIN
  
 Pressure to change the standard model of public procurement arose initially from
concerns about the level of public debt, which grew rapidly during the
macroeconomic dislocation of the 1970s and 1980s. Governments sought to
encourage private investment in infrastructure, initially on the basis of
accounting fallacies arising from the fact that public accounts did not distinguish
between recurrent and capital expenditures.

 Initially, most public–private partnerships were negotiated individually, as one-

off deals. In 1992, however, the Conservative government of John Major in the
United Kingdom introduced the private finance initiative (PFI), the first
systematic programme aimed at encouraging public–private partnerships. The
1992 programme focused on reducing the Public Sector Borrowing Requirement,
although, as already noted, the effect on public accounts was largely illusory. The
Labour government of Tony Blair, elected in 1997, persisted with the PFI but
sought to shift the emphasis to the achievement of "value for money," mainly
through an appropriate allocation of risk
 IMPORTANCE OF PUBLIC PRIVATE
PARTNERSHIPS

 Since the onset of the financial crisis last year, best estimates
suggest that the number of PPP deals closed has fallen 30 percent.
These difficulties have placed significant strains on governments
that have come to rely on PPPs as an important means for the
delivery of long-term infrastructure assets and related services.
 Moreover, this has occurred precisely at a time when investments
in public-sector infrastructure are seen as an important means of
maintaining economic activity during the crisis, as was highlighted
in a European Commission communication on PPPs. As a result of
the importance of PPPs to economic activity, in addition to the
complexity of such transactions, the
European PPP Expertise Centre (EPEC) was established to support
public-sector capacity to implement PPPs and share timely
solutions to problems common across Europe in PPPs.
 PRIVATE SECTOR IN INDIA
 At independence the private sector in India had only eight percent of
health care facilities (World Bank 2004) but recent estimates indicate that
93% of all hospitals, 64% of beds,85% of doctors, 80% of outpatients and
57% of inpatients are in the private sector.

 Contrary to commonly held views, private hospitals are relatively less

urban-biased than the public hospitals. Given the overwhelming
presence of the private sector in health, various state governments in
India have been exploring the option of involving the private sector and
creating partnerships with it in order to meet the growing health care
needs of the population.
 
 Public/Private Partnership would improve equity, efficiency,
accountability, quality and accessibility of the entire health system.
Partnerships are expected to ameliorate the resource constraints of the
public sector by reducing investments in expensive tertiary care services.
 VOLUNTARY SECTOR IN HEALTH
CARE
The voluntary health effort as it exists today, can be broadly classified as
follows:

 • Specialized Community Health Programs

 • Integrated Development

 • Health Care for Special Groups of People

 • Government Voluntary

 • Health Work Sponsored by Rotary Clubs, Lions Clubs and Chambers of Commerce

  • Health Researchers
 
 • Campaign Groups
 All voluntary initiatives are not necessarily in the area of
extreme needs.
 One finds very limited voluntary initiatives in the
BIMARU states (Bihar, Madhya Pradesh, Rajasthan and
Uttar Pradesh), as compared to the better-off states like
Kerala or Maharashtra. Even in Kerala, they are not
necessarily in the least developed parts of the Malabar
Coast or the highlands.
 Hardly any effort has been made to form public opinion
or mass organizations like trade unions, people’s
movements or political bodies, to generate a demand for
more appropriate and effective health services. In spite
of these limitations, however, the contributions of
voluntary health organizations in providing appropriate
health services in needy areas is highly appreciable.
 CHALLENGES IN PARTNERSHIP
Bennet et al. (1994) identified five main problems
associated with private-for-profit provision of
health services:
 Use of illegitimate or unethical means to

maximize profit.
 Less concern towards public health goals.

 Lack of interest in sharing clinical information.

 Creating brain drain among public sector

health staff.
 Lack of regulatory control over their practices.
 CHARACTERISTICS OF PARTNERSHIPS
 ADBI (2000) identifies the enabling conditions for the success of a partnership as:

 • A clear understanding between the partners about mutual benefits

 
 • A clear understanding of the responsibilities and obligations between the partners

 • Strong community support

 
 • Need for some catalyst to start the process of partnership (maybe an individual, a
donor, a compelling vision or even a political or economic crisis)
 
 • Stability of the political (government) and legal climate (laws)

 
 • Regulatory framework that is followed and enforced

 
 • Capacity and expertise of the government at different levels in designing and

managing contracts (partnership)

 
 • Appropriate organizational and management systems for partnerships

 
 • Strong management information system

 
 • Clarity on incentives and penalties.
 EQUITY AND ACCESSIBILITY
 
Partnership with the private sector presupposes that equity,
accessibility and quality of care would be ensured to the targeted
beneficiaries, i.e. the poor and deprived sections of the population.
However, verification of the authenticity of the poor patients is one of
the operational difficulties faced by field managers. Each partnership
project profiled here gave special privileges to the poor under various
contract clauses. Such services ranged from direct provision of clinical
care to providing services via insurance, vouchers, etc. In some
projects, upper limits have been placed on the utilization of services.
For example in Yeshasvini scheme, the patients are not allowed to
avail any medical treatment (inpatient admission) that does not lead
to surgery; and only two unmarried children plus a spouse of a co-
operative society member are allowed to avail benefits under the
scheme.
PRIVATE PARTNER SELECTION AND
OBLIGATIONS OF THE PARTNERS
 PERFORMANCE SPECIFICATIONS

 Some partnerships agreements mandate the private sector

to submit periodic reports but most indicate a monitoring
mechanism without specific details. It is widely believed
that, in government contracts, there is a tendency to
payless attention to the performance indicators. This is
based on a premise that the public sector itself does not
function efficiently and therefore would not be able to
identify
 performance standards and specifications. Another
premise is that if those who are in charge can use contracts
to obtain performance from the private contractors, they
 should use their influence to get required performance
from their own workforce.
 AUTONOMY
 One of the cornerstones of partnership is the relative
autonomy enjoyed by both the partners on day-to-day
operations as well as in the overall management of the
partnership. Autonomy is seen as non-intrusiveness by
the public sector and the freedom of the private agency
to take operational decisions without having to resort to
cumbersome bureaucratic approvals or being constantly
told about do’ s and don‘ts .
 In most of the projects the private partners are free to
decide what additional services to offer, free to generate
additional resources except through user-fees, and free
to appoint staff and determine their service conditions.
 QUALITY OF SERVICES
 One of the major gaps in partnership agreements
has been a lack of specific conditions related to the
quality of services to be delivered to the
beneficiaries.
 In most of the projects, the importance of delivering
quality services is stated, but not in specific terms.
Only the SMS hospital mentions that the private
agency is responsible for improper contrasts in the
CT/MRI images. Although most partnership
projects concern primary health care services,
specific quality parameters have not been taken
intoaccount.
 RISK- SHARING
Perception of risk depends on two factors:

 First, the rule-bound behavior of the partners

with strict disincentives for deviance;

 the second relates to the notion of trust

between the partners.
 At the policy level, the risks are rather political in nature.
 At the operational level, the risks for both the partners are
on many dimensions. There are financial risks,
performance and accountability risks, risk of confrontation
between stakeholders and reputational risks for the
private sector.
 While the for-profit private sector may well be capable of
withstanding any financial risks in the implementation of
the project, any error by a not-for-profit agency could close
down the organization.
 Accounting systems in not-for-profit agencies are usually
not sophisticated so errors lead to administrative strictures
or unforeseen complications.
 The government agency may have to delay the release of
funds until the error is rectified. A crisis of funds at this
stage could lead to stoppage of services to the
beneficiaries, further complicating the issue.
 STAKEHOLDERS PERSPECTIVES
 Beneficiaries in all the partnership project sites viewed the services
received by them in a positive manner, though often they were not aware
of any partnership. In general, feedback from the beneficiaries has been
that the services are better now than in the past. Very few patients have
been turned away from receiving services. Despite an overall positive
feedback from the beneficiaries, some concerns require attention from the
authorities.
 Another concern expressed by beneficiaries as well as private agencies is
a lack of clarity about who should pay user-fees and who is exempt.
 The main concern of the staff working under the private partners has
been that of high workload, long hours of work, lower pay, job insecurity,
political interference and staff turnover.
 The public health staff are not kind in their comments about the private
partnership projects, although they are willing to work with them. It has
been reported that health services are among the most corrupt civic
services in India.
 NATIONAL POLICIES FOR
INVOLVEMENT OF NGOs
 From mid-sixties, the government has envisaged a major role for NGOs
in the health sector.
 Since health is a state responsibility in India, this concern of the Central
Government is not very often shared in all the state governments.
Consequently, there has been uneven partnership between the
government and NGOs, depending on the political leaning of the
respective state governments.
 Very often, an NGO working at the grassroots with the community
perceives communicable diseases and reproductive health as a major
problem, whereas the government enthusiastically supports
 proposals that are target-oriented, pre-conceived and may not have
anything to do with the local realities. The partnership is further
complicated by the unequal nature of relationships and the red-tape
involved in getting programs sanctioned and the budget released from
the government.
VOLUNTARY HEALTH ASSOCIATION
OF INDIA
 Vision
 
 Voluntary Health Association of India (VHAI) is a Delhi-based national network of
more than 4000 non-governmental organizations spread across the country. It is one
of the world’s largest associations of voluntary agencies working in the areas of health
and development.
 VHAI was founded in 1970 with the goal of “making health a reality for all the people
of India.”
 
 Strategies
 
 VHAI strives to build a people’s health movement in the country by advocating a
cost-effective, preventive and promotional health care system through innovative
approaches in “Community Health.” Its programs are designed for health workers,
community leaders, voluntary agencies, professionals, social activists, media,
government functionaries as well as policy makers VHAI works closely with the State
Voluntary Health Associations, their member organizations and other network
partners.
 Focus Areas:
 
 • Facilitate research on vital issues and do campaigns, advocacy and lobbying both at
the central and state levels for evolving congenial policies aimed at improving the
health status of people.

 • Strengthen voluntary action through formation and support of state level

organizations.

 • Organize formal and non-formal training programs

 • Strengthen grassroots-level health care delivery by equipping village health

workers

 • Reach out to remote areas through comprehensive community health and

development projects.

 • Implement effective communication strategies

 
 • Disseminate and repackage information

 • Globally network with the UN and other international agencies for sharing of
expertise and resources.
Towards a More Fruitful Partnership Between the Government
and Voluntary Sector

Keeping in view the tremendous potentiality of the

voluntary sector in meeting critical needs, it has been proposed that
the following mechanism be put in place within the Ministry to
strengthen and encourage voluntaryeffort in key areas of health
care.

A National Co-ordination Committee, consisting of the Director

General Health Services, Secretary (Health), three representatives
from voluntary organizations and one representative from the
state government, should work as an active listening post for the
voluntary agencies working in the field of health. This committee
should meet periodically to monitor the implementation of the
committee’s recommendations, and provide inputs on the
planning and implementation of health services in the country.
Its functions should include:
 
• Promoting collaboration and co-operation between the government and
voluntary organizations in primary health care.
 
• Identifying people’s health needs and bringing them to the notice of
planners.
 
• Assisting in developing comprehensive national health policies and action
plans at all levels.
 
• Working out the modalities of administrative relationships between the
government and voluntary organizations for health care delivery to the
people.
 
• Identifying voluntary organizations at the state, district and block level
which are capable of taking up, in collaboration with government agencies,
health education, primary health care services and operational
research.
 
• Monitoring and providing feedback to the government on various National
Health Programs.
• Providing guidance and support to voluntary organizations in the health
field.
 
• Calling an annual convention of all voluntary organizations in health, to
provide healthy interaction between the health functionaries responsible
for policy-making and planning at the national level and various representative
voluntary organizations.
 
• Updating the national directory of voluntary organizations, which should
be a priced publication from which profits should be used to update the
directory every year.
 
• Organizing periodic quarterly meetings of the National Co-ordination
Committee.
 
• Sanctioning innovative projects in the voluntary sector to conduct research,
health service delivery and the production of educational materials
 
• Screening, monitoring, and evaluating, as well as providing support to all
the sanctioned projects.
 SUMMARY
Capacity of private partners and public sector officials towards
managing the partnerships is yet to be fully developed.
Public sector managers may perceive the new initiative as a
burdensome task, requiring them not only to placate their
subordinates but also to seek better performance from their
private partners. This is a daunting task.

Private partners, who are known for their informal and flexible
systems and organizational processes, are uncomfortable
with the rigid organizational and managerial processes and
procedures of the public sector. Bureaucracy is yet to become
conversant in the principles of New Public Management.
 
 
 
 CONCLUSION

Any policy initiatives to strengthen the flagging

public sector health services in India
would be welcome. But a government that fails to
deliver quality social services due to
lack of basic administrative capacity would not be
able to contract either clinical or
nonclinical services. The first step must be to
improve basic administrative systems.
 
 BIBLIOGRAPHY:-
 
 Government of India. 2005. Concept Note on Public Private Partnerships. New Delhi: Department of
Family Welfare, Ministry of Health and Family Welfare

 National Commission on Macroeconomics in Health. 2005. New Delhi: Ministry of Health and Family
Welfare, Government of India

 World Health Organization. 1999. WHO Guidelines on Collaborations and Partnership with Commercial
Enterprise. Geneva: WHO.
 
 World Health Organization. 2001. Making a Public-Private Partnership Work: An Insiders View.
Bulletin of the World Health Organization 79(8):795-796
 
 http://en.wikipedia.org/wiki/Public%E2%80%93private_partnership
 
 http://www.pppinindia.com/
 
 http://www.iitk.ac.in/3inetwork/html/reports/IIR-2004/Chap%205%202003.pdf
 
 http://medind.nic.in/haa/t08/i1/haat08i1p62.pdf
THANK
YOU!