Public-Private Partnerships (PPPs) is a term commonly used to define a relationship whereby [the] public and private sector [resources] are brought together to achieve a common purpose. PPPs are common across sectors (including the health sector) and geographical settings. The author of this article presents her perspective on the occasional loss of “partnership” in the truest sense of the word. A perspective on how the initial goal of the PPP might dilute into just the remnants of a relationship between ‘donor’ and ‘recipient’, and this in a setting she knows very well, the Sundarbans.
India, the world’s largest democracy, launched the National Rural Health Mission (NRHM) in 2005. This led to a sea change in public health service delivery – with a renewed focus on leveraging the public health sector to improve health indicators listed under the MDGs. With a population of 135 crores (1.35 billion), the country has 0.8 physicians/ 1000 people. A significant share of health care is provided by the private sector; outpatient care in rural areas of India is dominated by informal health providers across all income groups. The limited availability, access and affordability of healthcare, as well as the chronic shortage of health workers in remote and rural areas mean that people living in remote/rural parts of the country often seek care from unqualified private providers. One of the ways to strengthen the delivery of health services under the NRHM (now known as the National Health Mission (NHM)) was via public-private partnerships. Given the dominance of the private sector in India, PPPs offered a route to leverage existing resources to improve service delivery for all and bring in components of quality and regulation. Of course, it would be unfair to claim that PPP started with NRHM. Still, PPPs clearly got a boost under the NRHM.
Over the last nine years I have been working in the Indian Sundarbans, a mangrove area and delta with plenty of islands in the Bay of Bengal belonging to the eastern Indian state of West Bengal. The region suffers from geographical inaccessibility and frequent climatic shocks& monsoons. Road infrastructure has improved, but transport is still in poor condition. Health services are also (still) in a sorry state. 85 Percent of outpatient care for ailing children is provided by informal providers of which the quality of care is highly doubtful. Against this backdrop, even prior to the NRHM (i.e. since the late nineties), the State Health and Family Welfare Departments initiated some PPP initiatives to provide outpatient care to the remotest island(er)s of the Indian Sundarbans. NRHM brought further momentum to this effort, scaling up many of these PPP initiatives. Since the very beginning, however, these initiatives have faced service delivery challenges.
Lately, following an implementation research grant from the Public Health Foundation India (PHFI) and the Alliance for Health Policy and Systems Research (AHPSR), we had an opportunity to explore one of these initiatives – Community Delivery Centers (CDC). They intend to provide basic obstetric care in hard-to-reach terrain, are run by NGOs and financed by government health departments. With one of the Non-Governmental Organizations (NGO) as principal investigator, this implementation research effort aimed for a smooth collaboration between the implementing NGO and researchers. Thanks to this, we could explore the issue from both provider and beneficiary perspectives. The study was conducted in two (still running) CDCs and one that has been closed down now, and focused on exploring the reasons for different utilization of CDCs. Based on this research (but also our professional experience over the years in the region), we reckon a genuine ‘partnership’ between government departments and NGOs working in the sector is missing. In addition, the relationship between NGOs themselves is also rather competitive.
A CDC operates 24/7 with two doctors, two nurses and two paramedics. The contract (for health services at the CDC) between the public health department and bidding NGOs is yearly renewable. In this bidding process, NGOs often ended up getting the contract at the lowest cost, and had to follow few strict guidelines to ensure quality services. Since the service contract is renewable, however, the NGOs often failed to get it for consecutive years. Obviously, the human resources at CDCs also suffer from this (near constant) uncertainty. In remote islands of the Sundarbans this CDC is the only (nearby) source of delivery care. There are government facilities but only at block level [ In India, a Panchayat is the lowest administrative (rural) level; a block is comprised of a group of Panchayats ] and they are usually understaffed, whereas a CDC operates at village level and more specifically in the hard to reach islands of the Sundarbans. The payment to CDCs is as per the number of deliveries it performs in a year, so it’s performance-based. However, the payment from government often comes late. Therefore to run a CDC, NGOs first need to win the bid, and then need to bear the running cost until and unless government pays an amount back to them based on their performance. Given this delayed payment and uncertainty attached to it, one NGO failed to keep the physicians on board and had to close down. Our focus group discussion with the mothers in the region revealed that nowadays they are either going to a distant public facility which often fails to provide the service or they (have to) spend extra in private hospitals. A few of them are again practicing home delivery with the help of informal providers.
When doing this implementation research, our discussion with the implementing NGOs revealed that the NGOs are selected through a bidding process. As a result, NGOs are now more interested in cost-cutting and at times they even decide to stop service delivery, even if they have established infrastructure to deliver the services. One can well imagine how tough (and disrupting) it is in these hard to reach areas to first convince people to engage in healthy behavior and then, after such a yearlong effort, all of a sudden the service stops, and residents find themselves back to the vagaries of informal providers. The bidding process also leads to a sense of competition among the NGOs. You hardly see instances whereby one can use others’ infrastructure or an NGO fills in for another, continuing to provide the service for the people of the Sundarbans, if the first one decides to stop delivering services. The present research did not provide us with a chance to hear the public sector’s opinion in this regard, but the poor sense of ‘partnership’ on both sides was obvious. While NGOs are (obviously) more concerned with winning the bidding, the public sector seems happier with Management Information System reports and quality guidelines. NGOs report supervision from government officials but whether this supervision was supportive is questionable. Therefore a regular mechanism whereby both parties can meet and listen carefully to each other’s issues and work out solutions together, is very much desired.
Setting up a consortium could be another way to address some of the challenges towards more effective implementation of PPPs for the delivery of health services. If the NGOs could form a consortium, perhaps they would have more leverage in the contract negotiations with the Government and thus be able to ensure a more genuine “partnership” deal? The question is, though, who will bell the cat? This sort of consortium might only materialize if NGOs begin to understand the value of collaborating (rather than competing) or instead, if the government makes it mandatory to form one. Yet, such a ‘healthy partnership’ seems vital for ensuring universal health coverage. So, it is high time to work towards one, and make it sustainable and respectful.