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HEALTH SECTOR REFORMS: PUBLIC- PRIVATE PARTNERSHIP IN THE PROVISION OF HEALTH CARE SERVICES TO THE POOR
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Applicant(s) and institution(s) (university/ research institute/ NGO):
Applicant (1) / project director: Dr. A. Venkat Raman Position: Senior Lecturer in Public Systems Management Institution(s) of employment or affiliation: Faculty of Management Studies, University of Delhi South Campus Address: S.P.Jain Centre, Faculty of Management Studies, University of Delhi South Campus Benito Juarez Road, New Delhi – 110 021, INDIA Telephone: +91-11-2687 5875; 2687 5879 Fax Number: +91-11-2688 6427; 2687 3749 E-mail: venkat@iic.ac.in (or) venkatfms@yahoo.co.in Male or Female: Male Applicant(2) / project director: Professor dr James Warner Björkman Position: Professor of Public Policy and Administration Institution(s) of employment or affiliation: Institute of Social Studies (ISS), The Hague Telephone: +31-70-426 0589 Fax Number: +31-70-426 0799 |
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4. Project outline (max. 300 words): outline of the main research questions, the research methodology, the countries/regions to be researched and the potential social relevance of the research.
Over the years the private health sector in India has grown markedly. As budgetary constraints erode the capability of the public health system, the poor are forced to spend out of pocket to seek health care services from the private sector. Though unregulated and inequitable, the private sector is easily accessible, better managed, and a potent sector for realising public health goals. Public collaboration with the private sector in the form of Public-Private Partnership (PPP) would improve equity, efficiency, accountability, quality, and accessibility of the entire health system. While there are many innovative options available for PPP, there is little evidence to indicate the relative merits of one form of PPP over another that could help in developing a comprehensive policy towards the private sector. There is little evidence to suggest the institutional capacity of the government agencies to design, negotiate, implement and monitor such partnership, scope and coverage of the services for potential partnership with the private sector, required incentives and subsidies, transaction costs and savings, delegation and decentralisation of authority, performance and quality of services under existing arrangements, operational constraints, effect on the public health system, stakeholders’ perspective to this policy option, and whether PPP has been particularly designed to benefit the women, children, and elderly, etc.
There can be no effective and sustainable policy options unless these issues are studied in depth, systematically analysed, and documented. This study will (a) review and evaluate the experiences, including stakeholders perspective, in five selected states of India and in the Netherlands, through case studies on various forms of PPP, (b) compile documented evidence from Europe and other developing countries, and (c) identify the policy options, institutional necessities, and future directions for an enhanced role of private sector participation in the provision of public health services, targeted to the poor, women, children and the elderly. Stakeholders from government, patients, the private sector, development organizations, community groups, and bilateral and multilateral agencies will be extensively consulted.
Unless innovative and radical changes are brought about in the health sector, the poor and socially marginalized groups will continue to bear the brunt of inefficient public health system and the unregulated, inequitable private health sector. While PPP is considered to be an option for ensuring efficiency, quality and accountability of the health system, the task will be a big leap forward for government departments under the present circumstances. Therefore there is a need to find evidence-based ways to develop the capacity of the government institutions and systems towards this task. This study will provide insights into the experiences of PPP around the world and in India by highlighting the opportunities, challenges and policy options of decision makers, administrators, researchers, regulatory agencies and others in fostering private sector collaboration in the provision of affordable, and quality health care to the needy.
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Project duration (max. 3 years) and proposed starting date (preferably before 30 September 2003) |
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Detailed description of the project (insertion of additional pages is allowed, up to a maximum of 7 pages, using a letter type with at least 11 point font), including at least the following aspects: (a) problem statement and/ or hypothesis, and research question(s) (c) originality of the research: exploration of new/alternative approaches, perspectives or methods; and review of literature. (d) background/history of the project (e) co-operation with other national and international universities/ research groups
I. Background: India has one of the largest networks of public health institutions in the world. In 1999 there were 137,000 sub centres, 28,000 dispensaries, 23,000 PHCs, 3,500 urban family welfare facilities, 3,000 CHCs and 12,000 secondary and tertiary hospitals. Despite the vast network of health care facilities, public institutions for health care have not been able to deliver health care services at the desired quality and efficiency. A large proportion of population continues to suffer and die from infectious diseases, pregnancy and childbirth-related complications, and malnutrition. Public spending on health has remained stagnant at around one percent of GDP, of which approximately four-fifths of the budget is spent on salaries, leaving few resources for medicines, equipment and maintenance of existing services (Björkman 2001). Other major problems that afflict the public health care systems are: over-centralisation of planning and control of resources, lack of meaningful quality standards and quality assurance systems, imbalances in rural-urban/primary-tertiary care dichotomies, archaic management systems, lack of referral linkages, lack of accountability, absenteeism, indiscipline and low morale among the staff, large number of vacancies, insufficient pay and incentives, unsatisfactory working conditions, etc. As a result, even the poor and the most vulnerable sections of the population are forced to seek health care services from the private sector.
While the public health sector has many problems, there has been considerable growth of the private health sector in India. It is estimated that 80% of the health spending in India is out-of-pocket and that the private health sector in India is worth Rs.500-600 billion, which is around 5% of the GDP -- one of the highest proportions in the world. It is also estimated that 93% of all hospitals, 64% of all beds, 80% of doctors, 80% of outpatients and 57% of inpatients in India are accounted for in the private sector. The private sector provides 79% of outpatient care for those below the poverty line, much of which is of low quality and the payment is primarily out of pocket (World Bank 2001). While precise data and information on private health sector are still being collated, the private health sector is not only the most unregulated sector in India, but also the most potent and untapped sector. Although inequitable, expensive, over-indulgent in clinical procedures and without standards of quality or public disclosure of practices and pricing, the private sector is perceived to be easily accessible, better managed, and more efficient than its public counterpart.
II. Health Sector Reforms: The inherent inefficiencies of public health systems have long been well documented; they will be overcome only by radical changes in the way health care system is organised and managed (World Bank 1993). As budgetary constraints erode the capacity of the public health system, governments and policy makers are exploring alternative policy options and strategies not only to improve the efficiency, performance and quality of the public health system, but also to enhance the equity, accountability, and affordability of the private health sector. In the last few years, bilateral and multilateral development organizations have emphasized the need for and the importance of introducing significant reforms in the health sector. “Now is the time to carry out radical experiments in India’s health sector, particularly since the status quo is leading to a dead end. Now is the opportunity for governments to reform the way they work. 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” (World Bank 2001). Some of the policy options and strategies under health sector reform initiatives are: · alternative financing options (e.g. user fee, community financing, health insurance); · better institutional management systems (e.g. autonomous hospitals, partial privatisation, corporatization); · innovative personnel management systems (e.g. incentives, career avenues, redeployment, contract staffing); · decentralisation of administrative control to the Panchayat Institutions (PRIs) for facility maintenance, water supply, sanitation; and · collaboration with the private sector (Public-Private Partnership or PPP) by contracting out clinical and non-clinical services including staff, joint ventures, incentives and subsidies, handing over supervision and management of health facilities, etc.
While the relative efficacy of each of the above reform strategies is still being documented and debated, an important policy option for health sector reform involves encouraging the private sector to participate in provision of services under different kind of formal arrangements (partnership). Given the overwhelming presence of the private sector in health, various state governments are exploring the option of involving/collaborating / creating partnership with the private sector in order to meet the growing health care needs of the populace.
III. Public – Private Partnership: WHO (1999) defines partnership as a “means to bring together a set of actors for the common goal of improving the health of the population based on the mutually agreed roles and principles”. The core elements of partnership include beneficence (public health gains), non-malfeasance (must not lead to ill health), autonomy (of each partner), and equity (benefits to be distributed to those most in need). PPP does not necessarily mean collaborating with large corporate hospitals, nor does it mean direct contracts with clinicians, but rather finding ways to join hands with a broad spectrum of non-governmental actors. The private health sector comprises of all health care service providers who exist outside the public sector. They may be small or large, non-profitable charity organizations or commercially profit-oriented, operate in remote areas or urban centres, treat illness (curative) or prevent diseases (Mills et al. 2002). They could also be diagnostic centres, ambulance providers, blood banks, commercial contractors, religious institutions, industrial establishments, local or international development organizations, and community groups. It is also important to distinguish PPP from privatisation. Under pressure to economise, the governments may opt for partial or full privatisation, which is contradictory to the objectives of PPP, where large numbers of non-profit organizations are required to be involved.
PPP: Rationale, Objectives, and Experiences: It is important to understand why PPP is considered to be a policy option in the health sector. Some of the argued merits of PPP are:
a) Despite massive health infrastructure in place in India, there is still an enormous gap in the demand and supply of health care services. It is estimated that 3.6 million additional beds are needed in the health system, and the cost of each bed could vary from Rs 0.7 million to Rs 3.5 million (Purohit 2001), depending on the nature of speciality. The resource requirements are enormous and cannot be met by public financing alone. As the magnitude of private health infrastructure outstrips the public health system, augmenting the private resources is not only rational but also inevitable. b) Public partnership with the private sector is arguably desirable because the private sector is pervasive (easily accessible), caters to meeting the health care needs of a very large section of the population, has a distinct preference for patients, and is possibly cheaper ‘because they are adjusted to the purchasing power of the clients’ (Mills et al, 2002). c) Governments’ concern to reduce the financial burden of the poor who seek services from the private sector (out-of-pocket financing is not only inefficient but drastically increases vulnerability to poverty). While 40% of hospitalised Indians borrow money or sell assets to cover expenses, one quarter of all hospitalised Indians fall below poverty line because of hospital expenses (World Bank 2001). d) PPP could benefit the public health system by combining the different skills and resources of various organizations in innovative ways. Public agencies benefit from collaborating with the private sector in areas where the public sector has failed or has been unable or unwilling (Widdus 2001). “It is time to remove the blind spot to the private sector, by harnessing its energy and countering its failures" (World Bank 2001).
The objectives of PPP are to (a) utilise untapped resources and strengths of the private sector, (b) enhance the capacity to meet growing health needs, (c) reduce the need to invest in tertiary and specialty care, (d) reduce geographical disparity and reach remote areas, (e) improve efficiency through evolving new management structures, (f) facilitate expansion in areas where it has comparative advantage, (g) encourage the adoption of appropriate therapeutic norms and regimens, (h) promote participation in preventive and promotive care services by providing incentives, (i) increase efficiency through contracting out both clinical and non-clinical services, (j) strengthen linkages between government, NGOs and the local community (PRIs) for in the delivery of primary care, (k) expand capacity for monitoring, evaluation, and self regulation, (l) share information, (m) monitor the performance of public and private sector, (n) create health advocacy groups, and (o) support professional self regulation on costs, quality and equity (Bhat 2000; World Bank 2001).
Various forms of PPP have been tried all over the world. In India specific policies to promote PPP have been in the form of (a) networks with the private hospitals and physicians to develop disease surveillance data base (NADHI model by CMC, Vellore), (b) purchase of drugs and supplies in bulk (at cheaper rate) directly from the manufacturer and supply them to the small private hospitals and providers (Tamil Nadu), (c) partnership in managing high-risk pregnancies such as contracting specialist doctors (anaesthetists, obstetric & gynaecologists) in rural areas on case-payment basis (RCH programme), (d) collaboration in public health programmes (TB, polio, waste management, etc), (e) partnership in promotive care (social marketing, advertising, IEC, health education), (f) involvement of industrial houses for management inputs by adopting PHCs / health centres (Tamil Nadu) (g) privatisation or semi-privatisation of public health facilities, (h) innovative methods to mobilise funds through non-budgetary methods (hospital development committees, and community financing in Himachal Pradesh), (i) tax incentives, subsidies, rebates and duty exemptions for the import of medical equipment, incentives (subsidised land) to influence operations in desirable geographical locations (Punjab, Rajasthan), (j) joint ventures with large corporate hospitals for super speciality services (Delhi) in exchange for free care to the poor, (k) supervision and management control of public health facilities to a non-profit organization (Gujarat), (l) placing PHCs under the supervision of panchayat samitis (West Bengal), (m) philanthropic investment /donations in buildings, beds, equipment, with tax exemptions (Andhra Pradesh), and (n) contracting out- through competitive tendering process, non-clinical services (such as laundry, kitchen, dietary services, house keeping, security, transportation, maintenance of equipment, advertising, sanitation, landscaping) and some clinical diagnostic services such as contractual physician services (Bennett & Muraleedharan 1998; Palmer 2000; Bhat 2000; Muraleedharan 2001; Purohit 2001; Mills et al., 2002).
Partnerships could also include continuing medical education for private providers; involving traditional healers; employing private sector management approaches, leasing out or collocations, pay clinics (Catchlove 1998), service vouchers (Mills et al. 2002), and utilising the excess capacity of the private hospitals (The Lancet, 2000). Other potential areas where government could work closely with the private sector are contracting an independent body to monitor, evaluate and rate the public health institutions, working closely with medical councils, private providers and consumer forums to agree upon pricing, cost control, rational drug use, and quality assurance, enhancing R&D investment in drugs, pharmaceuticals and medical equipment (and protecting their patents and royalties), legitimately allowing public health manpower to be used by private providers in exchange for public health objectives, using ICT technologies for telemedicine, e-governance, health co-operatives, etc.
Among the wide variety of PPP strategies, contracting has emerged as the most prevalent form both in India and elsewhere. Contracting is usually justified in terms of lower costs, easier implementation and greater flexibility in the use of labour, improved efficiency through competition, greater accountability and transparency, improved quality of services at lower costs, decentralised managerial responsibility to induce a sense of commitment from each partner, and taking advantage of the relative strengths of each other, and easier access in case of clinical services (Mills1996, McPake & Hongoro 1995; Bately 1999; Palmer 2000).
IV. The Study: Despite its potential, PPP in health in India is at a very early stage. Initiatives are being evolved although there is no consensus on what should be the private-public mix in health care nor, in fact, what should be the public policy towards private sector. Since this task will be a big change for government departments, there is a need to find evidence-based ways to develop the capacity of government institutions and systems towards this task. However, little evidence is available for initiating policy discussion on the merits and demerits of various forms of PPP. There is a lack of documentation on some key innovations that have been taking place in India, including areas such as contracting of services in the public sector, partnership between public and private sector, payment systems, and the use of subsidies, and other such critical questions. Even in the few instances where partnership had played a role, no study has been carried out to evaluate its impact or to study the factors for the success (or failure) or to compare the outcomes of PPP with those of alternative policy options (World Bank 2001, Muraleedharan 2001).
At the policy level, some issues that need in-depth analysis are whether government should directly propose and handle the PPP initiatives, or whether it should create a specialised, independent agency for this task, or whether this task should be decentralised to district level functionaries, including the PRIs -- and the relative merits and demerits of each approach? What is the relative efficiency of one mode of partnership over other methods in the achievement of public health goals? How can PPPs be designed to target and benefit the poor, women, children and the elderly? What incentives would encourage higher levels of private sector involvement in the provision of health care services to the target groups mentioned? Is it more effective to subsidize inputs or provide direct subsidies to the poor by purchasing the services from the private sector? How much does the bureaucracy need to modify its rules and procedures to allow these initiatives to take place? What should be the administrative authority of the health facility managers, and the incentives to the managers in initiating, negotiating and supervising a partnership? To what extent have stakeholders been consulted in the formulation of existing guidelines? It is argued that many of the problems of PPP have occurred because of the lack of institutional capacity of the government to design and draft a comprehensive policy towards PPP. There are shortages of managerial skills in designing, costing, negotiating, co-ordinating, and managing the partnership deeds (MOUs), and lack of resources required to monitor the outcomes, etc. It is essential to analyse these dimensions.
Popularity of contracts as a reform prescription highlights the need to understand their nature and the manner in which they operate. Limited documentation on contracting in India does not provide enough evidence to indicate the advantages and disadvantages of contracting, the extent of contracting, scope and coverage of the contracts, transparency in evolving and executing a contract, the transaction costs and savings, effect on health manpower and resources, relative efficiency of the type of contracting vis-à-vis nature of services contracted, quality of services provided, constraints that affect the capacity of the government to contract and monitor, legal and administrative pitfalls faced by both the partners, the competence of the health sector managers to negotiate, implement and monitor such contracts, availability of suitable management information system, perceived trust of the private providers towards government intentions, and the internal stakeholders’ perspective (or opposition) to such policy options.
At the operational level some of the questions that merit in-depth analysis include, who are the eligible private sector groups, what are the criteria for their selection, incentives and disincentives (penalties), how the powers are delegated under the existing bureaucratic framework, procedures required to seek approvals and reimbursements from different government functionaries, monitoring mechanisms, alternative arrangements in case of retrenchment of funds or withdrawal/ termination of partnership, autonomy to hire and fix wages, etc. These issues merit in-depth study and analysis with experiences documented in a systematic manner. Several specific questions that will be addressed in this study are:
ü What are the proposed forms of PPP by various state governments? What are the definition, scope and coverage, and methods of PPP against a particular kind of health care services? ü Are there any formal policy guidelines (of any state government) towards not only promoting PPP, but on private health sector as such? If there are such policy guidelines, what is the scope and coverage of such partnership? What are the public health objectives and goals in the policy guidelines? What is the response of the private sector towards these policy guidelines? ü Do the policy guidelines specifically define and address the needs of the poor patients? If so, what are the mechanisms to ensure the equity as well as the quality of care for poor patients? ü Have the policy guidelines been developed considering stakeholders’ perspectives or interests? Are the policy guidelines detailed and transparent with options for public scrutiny? ü Who are eligible partners and how are the eligibility criteria determined? What specific conditions, such as geographical specification, must be fulfilled? ü What are the incentives and support systems (tax breaks, subsidies) made available to the private providers? ü Are price, quality, clinical standards, and accessibility conditions for the patients clearly mentioned in the agreements or MOU? ü What is the authority and incentives of the health facility managers to supervise and monitor the functioning of the private provider? Are they adequately trained to manage such unconventional methods of public health care? ü How will the other departments of the government (land authority, finance and revenue, etc) be co-opted and co-ordinated? ü What are the past experiences of PPP in different forms and in different areas? What are the best practices, deficiencies and bottlenecks? Are there any exit / termination options for either of the partners? If so, how easy or difficult is the exit process? ü Are the legislative and regulatory frameworks in place for protection against unwanted litigation? Are the private providers adequately informed about the regulatory requirements in order to avoid misconceptions or disagreements? ü Are there sufficient guidelines to link various levels of the health systems with the private providers’ services? ü Would it be cost effective for the government to set up and manage its own health facilities (‘Make’) or develop institutional mechanisms and management capability to design, implement, regulate and monitor partnership with private sector (‘Buy’) in preventive and promotive services or remote locations? ü What are the justifications behind the current private sector involved programs implemented by various state governments? ü What is the ability of the government to conduct cost benefit analyses of various PPP options, to formulate and negotiate PPP plans, to supervise and monitor the quality of performance and outcomes, to create incentives (or penalties) to the private sector as well as incentives to the internal stakeholders for better supervision? ü Is partnership with the “for profit” private sector more efficient than with NGOs and charitable institutions? ü Who are the supportive stakeholders and opposing stakeholders, and the bases of their support or opposition? Has PPP lead to substantial reduction in staff level? ü Would any form of PPP lead to reductions in the government spending on public health system?
Effective and sustainable policy options will remain elusive unless these questions are addressed. The existing research evidence provides no clear answers to these questions. This research study is formulated to address these issues.
Objectives of the Study:
§ Prepare a comprehensive report and annotated bibliography, based on an exhaustive review of research evidence from the experiences in India, Europe and other countries, about the various types of PPP, the nature of services provided, their relative efficiency, quality and performance, and their contribution towards meeting public health goals.
§ Compile and review the formal policy/vision statements, statutory procedures and guidelines (from government records) for promoting PPP, particularly targeted towards maternal and child health, care of the infants and the poor, by various state governments in India and in the Netherlands, and prepare a baseline report.
§ Conduct in-depth case studies and vignettes of innovative methods of PPP, in five select states in India, and in the Netherlands.
§ Evaluate the relative performance, efficiency and quality of services provided by the private providers under PPP and seek feedback and views from internal and external stakeholders on their experiences with PPP in terms of performance, quality, accountability, relative merits, and prospects of PPP.
§ Identify the policy options, institutional necessities, and future directions for an enhanced role of private sector participation in the provision of public health services to the poor and the needy.
Methodology
Operational definitions
For the purpose of this study, the private (non-public) sector includes ‘for profit’ individual physicians/nursing homes/ hospitals, private commercial contractors/agencies, and ‘not-for-profit’ developmental organizations, charitable institutions, industrial establishments, community associations, citizen groups and PRIs.
The types of health services include clinical care services or non-clinical support services/activities either in static hospitals or mobile services, in rural and urban areas. They also include preventive health care programs (e.g. ANCs, institutional deliveries, immunization, post-natal care, etc), and health promotion programs (e.g. IEC, social marketing of RCH programs, and health education activities).
Stakeholders include patients, physicians, staff unions, administrators (bureaucrats and health sector managers), contractors, private hospitals, NGOs, charitable institutions, citizen groups, and community and panchayat leaders.
Data collection will be limited to five major forms of Public-Private Partnership: (a) competitive tendering process leading to contracting out services-clinical and non clinical services, (b) delegating the supervision and management control of the health facilities or services to private sector, (c) managing high-risk pregnancies through referral linkages, and contracting specialist doctors, (d) linkages with private sector for disease surveillance information and health promotion activities, and (e) innovative methods of mobilising funds from private sector.
Information categories
As stated earlier, there is a need to comprehensively review the PPP experiences from all possible perspectives, which is lacking in the limited evidence currently available. It is therefore envisaged to collect detailed information and data on the following aspects (e.g. contracting form of PPP) from the state governments and the private sector in respective states. These are, formal policy statements/guidelines; profile of implementing agencies; type of information to prospective bidders; contract /MOU rules and clauses; proposed form of participation; scope and coverage of services to be provided; eligibility requirements; minimum investment; interdepartmental co-ordination; contract procedure; number of bidders; items negotiated; duration; payment mechanism; revenues generated; constitution and functioning of management board; location specification; public health objectives with specific focus to poor, women and children; price and service specification; quality control and supervision; employment/service conditions to the staff; physical infrastructure support; subsidies and incentives; penalties and fines; exit clause; grievance redressal system; performance evaluation; renewal of contracts; maximum number of contracts to one agency; feedback and satisfaction of the stakeholders; implementation bottlenecks, etc.
Data collection
Secondary data on India, Europe, and International experiences on PPP will be reviewed through an exhaustive literature search of research papers, articles, reports, and other documents, from library resources, databases, websites of WHO, World Bank, Medline/Pub-med, DFID, OECD, EU, other international development agencies, library resources at ICSSR, ISS, National Medical Library, and other research organizations. The partner researcher at ISS will collate research evidence on Europe.
Government documents on policies, statutes, plan documents, government notifications, circulars, advertisements, MOU or contract agreement documents, will be collected from five state governments in India, in detail during field work, and also in the Netherlands. Policy guidelines, if any, on PPP from as many as fifteen states will be collected through mailed requests to the respective state MoHFW, to be followed up with resident commissioners of each state in Delhi, as well as with assistance from a research institute in the respective states.
Primary data such as developing in-depth case studies, collecting anecdotal evidence, stakeholder feedback, and survey of private providers’ perspectives, will be collected through fieldwork in five states in India (Madhya Pradesh, Rajasthan, West Bengal, Andhra Pradesh, and Tamil Nadu). It is proposed that at least one case study on each form of PPP (1x5) will be compiled from each state (i.e. a minimum of 25 case studies, from all 5 states). In the process of compiling the case studies, detailed discussion (in the form of interviews/ focused group discussion) will be carried out with as many stakeholders as possible, in respect to each case. It is proposed to hold discussion with at least 20 beneficiaries (patients), five service providers (physicians/ contract staff), senior representatives of the staff union (from physician, nursing, paramedical staff, and class IV staff unions), senior representatives from few community groups (clubs, associations), senior administrators of the health facility (and also at the district, and at the MoHFW level), senior administrators of the private provider or contractor, representatives of industry associations (chamber of commerce), and panchayat leaders will be held. It is also proposed to hold discussion with the state health ministry bureaucrats, policy advisory groups, and members of the consumer advocacy groups. Feedback on the quality, satisfaction, performance and benefits will be collected through a structured questionnaire, in the form of surveys. For the purpose of this survey, the stakeholders will be divided in broad categories of ‘provider’, ‘purchaser’ and the ‘beneficiary’ groups. Prior to detailed interaction with the stakeholders, a pilot study will be carried out in one of the states on all five types of PPP initiatives to finalise the issues, variables and questions. Data on performance indicators will be collected to evaluate the efficiency, quality and performance of the private providers.
Discussions, interviews, and an internet-based survey will be carried out with those bilateral and multilateral development organizations, in the Netherlands and elsewhere in Europe, that are actively engaged in health sector in India and other developing countries (e.g. NORAD, SIDA, DFID, OXFAM, DANIDA, GLRA, etc). This survey/discussion will seek feedback on their experiences, problems, and policy options on PPP in the developing countries, with specific focus on India. During this process, documented evidence from these development organizations will be compiled.
Information and data will be subjected to appropriate qualitative, statistical, and non-parametric analysis.
This IDPAD study will be collaboration between the Faculty of Management Studies, University of Delhi, India and the Institute of Social Studies, the Netherlands. During data collection and fieldwork, assistance and co-operation will be requested from one research institute from each of the Indian states (for example IIHMR, Jaipur, for the state of Rajasthan). Data from the Netherlands and other parts of Europe will be collated with the help of the Co-Principal Investigator. Case studies of PPP in the Netherlands will be scheduled. References:
· Bately, R. 1999. The New Public Management in Developing Countries: Implications for Policy and Organizational Reform. Journal of International Development 1195:761-765 · Bennett, S. & Muraleedharan, 1998 The role of government in adjusting economies: Reforming the role of government in Tamil Nadu health sector, Development Admin. Group, University of Birmingham & Health Policy Unit, LSHTM: London, Report no. 28 · Bhat, R. 2000. Issues in Health: Public-Private Partnership. Economic and Political Weekly 30:4706-4716 · Björkman, JW. 2001. Multiple Systems, Multiple Reforms: South Asian Health Policies in Comparative Perspective in Handbook of Global Technology Policy edited by Stuart S Nagel. New York: Marcel Dekker, Inc. Pages 167-220 · Björkman, JW and Kuldeep Mathur. 2002. Policy, Technocracy and Development: Human Capital Policies in India and the Netherlands. Delhi: Manohar Publishers. · Catchlove, B. 1998. Public-Private Partnership in Australia. Hospital Quarterly 1(2) · McPake, B. & Hongoro, C. 1995. Contracting Out of Clinical Services in Zimbabwe. Social Science and Medicine 41(1):13-24 · Mills, A. 1996 Contractual relationship between government and the commercial private sector in developing countries: Are they a good idea in health?, in Bennett, S., McPake, B, and Mills, A. (ed.) Private health providers in developing countries: Serving the public interest? :London, Zed press. · Mills, A. & Broomberg, J. 1998. Experiences in Contracting: An Overview of the Literature (WHO technical paper 33, Geneva) · Mills, A., Brugha, R, Hanson, K., and McPake, B. 2002 What can be done about the private health sector in low-income countries? Bulletin of the World Health Organization, 80: 325-330 · Muraleedharan, V.R. 2001. Public-Private Partnership in Health Care Sector in India: A Review of Policy Options and Challenges. Private Health Sector in India: Review and Annotated Bibliography. Mumbai, CEHAT · Palmer, N. 2000 The use of private sector contracts for primary health care: Theory, evidence and lessons for low income and middle income countries, Bulletin of the World Health Organization, 78(6): 821-829 · Purohit, B.C. 2001. Private Initiatives and Policy Options: Recent Health System Experience in India. Health Policy and Planning 16(1):87-97. · The Lancet. 2000. News item. 356:1663
· WHO 1999. WHO guidelines on collaborations and partnership with commercial enterprises, Geneva, WHO. · Widdus, R. 2001 Public- Private partnership for health: Their main targets, their diversity and their future directions, Bulletin of the World Health Organization, 79: 713-720 · World Bank. 1993. World Development Report – Investing in Health. Washington, DC · World Bank. 2001. India - Raising the Sights: Better Health Systems for India’s Poor. (Report no. 22304, HNP Sector-India) Washington, DC
Description of the social relevance of the research for India (insertion of additional pages is allowed up to a maximum of 1.5 pages, using a letter type with at least 11 point font):
Social relevance and utility of the study:
Public-Private Partnerships provide a potent innovation in the health sector. Public partnership with the private sector is arguably desirable because the private sector is pervasive (easily accessible), caters to meeting the health care needs of a very large section of the population, has a distinct preference for patients, possesses formidable resources, is more efficient and better managed. However, the private sector is also expensive, inequitable, unregulated, and lacks quality standards. The worst affected by the anomalies and inequities in the health system are the poor who, forced to seek health services from the private sector due to inherent deficiencies in the public health system, must pay out-of-pocket. While the private health sector will continue to thrive, it would be the responsibility of the government to augment private sector resources, and to use their management skills to improve the overall efficiency, equity, access, and quality of the health system in general. Therefore public partnership with the private sector is not only rational but also inevitable.
Despite its vast potential, PPP in health in India is at an early stage. These initiatives are hindered by the lack of evidence-based policy on what should be the private-public mix in health care. The questions to be addressed are how the government could regulate and monitor the private sector, in what way could the government forge a partnership with the private sector to cater to the health services needs of the poor and marginalized groups, what are the merits and demerits of different various types of PPP, what are managerial and administrative capabilities required by government in designing, negotiating and managing any partnerships, what organizational system changes are required for such initiatives, what incentives, penalties, and regulatory structures are required, what are the experiences in India and around the world on various forms of PPP, and how do these experiences help in developing a comprehensive PPP policy, guidelines and procedures in India.
This study will provide insights on the experiences of PPP around the world and in India. The study will generate reports on (a) various types of PPP documented from countries around the world; (b) the experiences of PPP from five state governments in India and in the Netherlands; and (c) policy options for enhanced co-operation between public-private sector in delivering health care services more efficiently. The study will identify and document the policy options, scope and coverage of the PPP, relative merits and demerits, the specific procedures and guidelines, the organizational and administrative systems required, opportunities and challenges for decision makers, administrators, researchers, regulatory agencies and others in fostering private sector collaboration in the provision of affordable, and quality health care to the poor and the needy. The findings of the study could provide future directions in adopting and experimenting with innovative methods of PPP in India.
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Composition of the core research team: per institution involved provide the following information on the principal researcher(s) participating in the project:
I. (a) background information
- name: Dr. A. Venkat Raman - institution of employment: Faculty of Management Studies, University of Delhi, India - current position: Senior Lecturer in Public Systems Management - date of birth:09th May, 1962 - male/ female: Male - nationality: Indian - academic degree: M.A.(Tata Institute of Social Sciences); Ph.D. (Faculty of Management Studies) - date(s) of graduation/ doctorate/PhD: M.A. (1984); Ph.D. (1998) - university: University of Delhi, India - field of academic specialisation: Public Systems Management (Health Systems) and Human Resources management
(b) specific task(s) in the project: Principal Researcher in India; overall supervision, co-ordination, and management of the research project in India; responsible for the specified outputs from the study;
(c) particular qualifications relevant to this project/ previous research experience:
The Indian Principal researcher has handled research projects from WHO, World Bank in the past; Is currently involved as research advisor in an European Commission on Health and Family Welfare project on health sector reforms in the Indian state of Haryana, and as a research consultant in a Population Council, (Washington, DC) operations research project in India, for developing national level hospital guidelines for HIV/AIDS patient care. Member in a three-member committee to review the functioning of the health department of the municipal corporation of Delhi. The researcher also supervised a number of research projects and dissertations on health sector in the Faculty.
II. (a) background information
- name: Professor dr James Warner Björkman - institution of employment: Institute of Social Studies (ISS), The Hague - current position: Professor of Public Policy and Administration - date of birth:12th November,1943 - male/ female: Male - nationality: American (permanent resident in the Netherlands) - academic degree: M.Phil.; Ph.D. - date(s) of graduation/ doctorate/PhD: MPhil (1969); PhD (1976) - university: Yale University - field of academic specialisation: Public Policy
(b) specific task(s) in the project: Principal Researcher in the Netherlands; overall supervision, co-ordination, and management of the research project in the Netherlands; jointly responsible for the specified outputs from the study
(c) particular qualifications relevant to this project/ previous research experience: The Netherlands-based principal researcher has conducted health policy research for over thirty years, had had forty years association with South Asia, and has published extensively. He is on the editorial board of Public Organization Review and has served on many health care advisory committees. He is also primary supervisor for PhD dissertations in public administration, administrative reforms, and political science and development studies.
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12. Relevant publications of the research team (maximum 10 publications):
Venkat Raman, A. and P. Raju. 1999. Evaluation of mobile health scheme in the urban slums of Delhi, The Journal of Institute of Public Enterprises 22:114-128.
Venkat Raman, A. 2002. Institutional Reforms in Health Sector: Study of personnel and organizational issues in select health sector reform projects in India. Robert S McNamara (World Bank) fellowship research report. Washington, DC: World Bank.
Venkat Raman, A. & Hemanth, K. (2002). Contracting Out Support Services in Select Public Hospitals in Delhi” (research report) Faculty of Management Studies, University of Delhi.
Venkat Raman, A. “Those who matter”: A group based stakeholder analysis activity for health service organizations, HRD Annual, Portage: Pfeiffer Annuals, (forthcoming 2004 issue).
Björkman, JW and Altenstetter (ed.) 1997 Health Policy Reform, National Variations and Globalization. London: Macmillan.
Björkman, JW. 2001. Multiple Systems, Multiple Reforms: South Asian Health Policies in Comparative Perspective in Handbook of Global Technology Policy edited by Stuart S Nagel. New York: Marcel Dekker, Inc. Pages 167-220.
Björkman, JW and Kuldeep Mathur. 2002. Policy, Technocracy and Development: Human Capital Policies in India and the Netherlands. Delhi: Manohar Publishers.
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