COMMENTARY
Public-Private Partnerships and Health Policies N S Prashanth
In view of poor public service provision in many low/middle income countries, a strong move to partner with the private sector is often advocated as a simple and obvious solution. In India, the private sector is widespread and unregulated and this solution appears to be innovative as well as feasible. However, research in this field is scarce and in the lack of evidence, health policy is increasingly dependent on rhetoric or single case studies showing success in specific contexts.
We would like to acknowledge Guy Kegels for his inputs and the emerging voices team at the Institute of Tropical Medicine, Antwerp for their enthusiasm in supporting young researchers from the global South. A shorter version of this article was selected for Emerging Voices from the Global South by the Institute of Tropical Medicine, Antwerp in November 2010. It was presented at the First WHO Symposium on Health Systems Research, Montreux in November 2010. N S Prashanth (
[email protected]) is with the Institute of Public Health, Bangalore.
We don’t know half of how healthcare works as well as we would like; and we like less than half of how it works, as much as it deserves.1
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ndia is a nuclear power with anaemic mothers; an irony of sorts for a country with 9% economic growth, still grappling with problems of access to healthcare. Inequities range from a curious mix of the technology of tomorrow in Bangalore to malnutrition and infant deaths a few hundred kilometres outside the city. Three out of four children have severe anaemia linked to poverty, lack of food security and poor maternal health (Pasricha et al 2010). While urban areas reel under the side effects of economic growth and urbanisation, the rural areas are still stuck with an unresolved backlog of partially successful vertical programmes. The double burden of chronic non-communicable diseases and the infectious diseases continues to form a significant health burden for the people; a huge body of published research on chronic disease contrasts with a lack of practical implementable solutions for continuous care for these conditions on the ground (Bermejo et al 2011). India stands out in being characterised by a largely patient-financed health system that is prone to catastrophic health expenditure leading to poverty (Devadasan et al 2007; Xu et al 2003). Access to primary healthcare is a far cry in several regions; in some parts of the country people walk through rainforests for no less than five days to reach a poorly staffed and ill- financed health centre. Else, they pay out of their pockets at the time of illness for expensive in-patient services in distant cities. Nearly 8% of India’s indigenous tribal people are still grappling with questions of ownership over lands they live on and their conservation ethic itself is being called into question when they hunt endangered wildlife (Bijoy 2011). Understandably, malaria mortalities in such forest areas with tribal communities are as frequent as the hunting of wildlife; public health entwined in a
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complex web with implications for achieving wildlife conservation through universal access to healthcare (Velho et al 2011). As one of the signatories of the declaration of Alma-Ata (and an early convert to comprehensive primary healthcare), India has developed a huge public health infrastructure. However, the healthcare system is a heterogeneous one with a mix of un organised and largely unregulated private for-profit sector and a burgeoning non-profit network of voluntary non-governmental organisations (NGOs). While there have been large investments by the government and through World Bank assistance to indivi dual states in building up public health infrastructure, there has been a disturbing underutilisation and widespread corruption (Ministry of Health and Family Welfare 2005; Sudarshan and Prashanth 2011).
The Case for PPP In this scenario, it is easy to build a case for partnership between the State and the private sector and indeed there has been an unprecedented proliferation of publicprivate partnership (PPP) schemes in health (Raman and Björkman 2008). NGOs are contracted in to provide a gamut of services ranging from health extension services such as operation of mobile primary healthcare vehicles in remote areas, emergency obstetric care through private ambulances to maternal healthcare through voucherbased reimbursement of privately provided services. Contracting primary health centres to NGOs has captured the attention of policymakers as a useful tool especially by handing over of poorly performing primary health centres (PHC) to private sector with the expectation that the private partners would improve services at these PHCs. But the takers for the scheme have remained few; in Karnataka, out of 2,195 PHCs, 56 are being run by NGOs.
The Gumballi Experience One of the first such PHCs to be handed over to an NGO was the Gumballi PHC in Chamarajanagar district in southern Karnataka. The village Gumballi is about 200 km south of Bangalore. An NGO, Karuna Trust (KT) took over the management of this PHC in 1996. Having worked at this PHC as a medical officer (2005-06), I saw the acceptance by the community of the services
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COMMENTARY Table 1: Key Health Indicators of Gumballi PHC Compared to Karnataka State
Gumballi PHC State (2006)
Crude birth rate per 1,000 population 17.5 Crude death rate per 1,000 population 4.6 Infant mortality rate per 1,000 livebirths 23.6 Perinatal mortality rate per 1,000 livebirths 9.3 Neonatal mortality rate per 1,000 livebirths 13.9 Per cent of women receiving three post-natal checkups 100 Per cent of institutional deliveries 81
20.1* 7.7# 48.7$ 35.3# 28.9# 60## 65##
* Sample Registration System data (2007), Government of India. # Sample Registration System data (2003), Government of India $ National Family Health Survey 3 (2006), Government of India. ## District-level Household Survey (2004), Government of India. Source: PHC data from monthly reports of Gumballi PHC. Ghanshyam (2008: 878-79).
Table 2: Utilisation of Out-patient Services at Gumballi PHC Compared to the Nearest Government-run PHC during January to December 2006 PHC
Population Male
Sugganahalli (KT) Kudur Gumballi (KT) Honnur
14,108 5,257 4,089 3,271 12,617 16,174 3,783 3,063 1,562 8,408 21,165 13,309 10,590 4,214 28,113 16,588 3,683 3,420 132 7,234
Female Children Total
Source: Out-patient registers of the PHC.
in the PHC. KT implemented “innovations” – services that were not a part of the package of services provided by the State such as community health insurance, mental healthcare at PHC through trained doctors, tele-electrocardiography (ECG) services and mainstreaming traditional medicine. KT improved availability of staff through effective supervision. There have been no reports of deliveries without a trained birth attendant within the Gumballi PHC since 2003. The infant mortality rate in the area served by the PHC decreased from 75 per 1,000 live births in 1997, one year after the PHC was taken over to 24 per 1,000 live births in 2004. The good record of institutional deliveries at the PHC shows that the acceptability of services is good; something that the public services are struggling with in most places in the country. The increasing utilisation rates and a few indicators (Table 1) show that availability and access to care has improved in some PHCs run by KT (Table 2). Studies on PPP in primary healthcare and how it improves health services are scarce especially so in India. Most literature presently appears to be advocacy documents either by the NGOs involved in PPP or by activists opposed to the idea. However, the adoption of PPP in health by governments is in contrast to how well we understand PPP; the National Rural Health Mission (NRHM) launched by the Indian government,
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a landmark reform in the country enshrined PPP as an important strategy in its mission document. There seems to be a confident adoption of one policy option – the PPP – over another (state provision of services) on apparently technical grounds.
Poor Evidence for Policy Options The blanket application of PPP as a policy panacea for achieving better healthcare rings alarm bells not merely because of doubts on whether PPP works or not; nor because of the ideological debate about state provision versus private sector provision of services, but because of the foundations on which policy alternatives are chosen. Even as the World Health Organisation (WHO) has chosen health research for its 2012 world health report theme, declaring “No health without research” and the calls for evidence-based policymaking get louder, the glaring gaps in actual evidence available emerge. Part of this problem stems from the dichotomous policy-view “does it work?” leading to the policy trap of accepting yes or no answers to complex questions determined by “what works for whom and under what conditions”. This “policy trap” is amusing akin to asking Thor Heyerdahl2 “Does rafting across the Pacific work?” in comparison to asking the few who failed or the multitude who never ventured and just had strong opinions about it. Often neglected in health research are these scientific evaluations and implementation research that provide useful policy answers.
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Approaches to organising and delivering primary healthcare suffer from a lack of proliferation, as there is no market-driven trend to innovate in an area ridden with market failure. Several functions of comprehensive primary healthcare are indeed demonstrably not profitable in the shortterm thus keeping short-term for-profit sector from delivery of comprehensive primary healthcare, although there are scattered examples of specific primary clinical services delivered by the private for-profit sector. The push for PPP initiatives in health also neglects the nature of the private entity, often never making the distinction between ownership of the private entity (state and non-governmental) or the goals Table 3: Framework to Distinguish ‘Public’ and ‘Private’ Based on Ownership and Goals
Public Goals Private
Public
Ownership
Public-oriented state institutions For-profit oriented state institutions
Private
Public-oriented NGOs Private forprofit sector
Based on Giusti et al 1997: 193.
(public-oriented or profit-oriented) (Giusti et al 1997: 193-98). In Table 3, what is presently lumped under PPP may fall in any of three arrangements other than the private for-profit sector.
Path-Dependence and ‘Lock-in’ In classical economics, the path-dependence model of increasing returns states that organisations tend to become path-dependent in view of the positive feedback that
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[email protected] Circulation Manager, Economic and Political Weekly 320-321, A to Z Industrial Estate, Ganpatrao Kadam Marg, Lower Parel, Mumbai 400 013, India october 15, 2011 vol xlvi no 42 EPW Economic & Political Weekly
COMMENTARY
they get from merely being on a particular path. This has been used to explain how the QWERTY (on the key board) model of the typewriter made it into computers because of the universal acceptance, in spite of its less efficient design when compared to the later introduced DVORAK keyboard (David 1985). This design migrated to the computer keyboards too, and no re-look at efficient keyboard layouts was considered at that time. More recently, the evolution of the Internet or wide usage of apparently “inferior” software programmes can also be explained similarly. In the rapidly changing field of technology, where economic returns and “success” are influenced by market penetration and brand history rather than beneficial effect to end user, a lock-in of apparently “inferior” technologies can occur as explained by path dependence (Boas 2007). In the lack of competition for the “technology” or “model” like in the case of PPP in primary healthcare, this “lock-in” may be even more severe and the motiv ation for striving to improve the models is much lower and often not because of competition but rather due to the “public- orientedness” of the partner.
Case for Implementation Research Implementation research can help break through such lock-in by informing managers and policymakers on how the various initiatives fare in given contexts and in what ways the design of policy alternatives such as PPPs can benefit from implementation research. In the absence of such research, policy leans on opinions, rhetoric and ideology. Such research needs to ask the question of “how” things work rather than “do things work” to avoid the policy trap (ibid).
Summary Over the last decade a slew of initiatives to improve public expenditure on people’s health have been taken up under the NRHM. PPP has figured prominently in NRHM as well as several advocacy documents. There have also been some anecdotal success stories and possibly unstudied and failed PPPs. However, policymakers have little to go on in terms of evidence, scientific evaluations or studies to base their decisions. Implementation research to study such innovative processes is the need of the
hour and there have been strong calls for this in public health literature over a decade ago and more recent endorsements at the global level (Alliance for Health Policy and Systems Research 2004; Chopra and Sanders 2000). They urge to move away from the choice between “good” and “bad” policy options and understand why and how certain interventions work in certain settings. In the jargon-rich world of public health, it is easy to reduce PPP to merely contracting-out of institutions or service delivery and dole out policy briefs promoting large-scale PPPs in primary healthcare based on the few that worked, and neglecting the multitudes that did not. Similarly, it is also easy to think of PPP as a step towards privatisation and oppose anything under the term PPP. However, both such positions are devoid of understanding the mechanisms through which it works (or does not). And the scapegoat in this debate is an understanding of how such initiatives work. Although, based on a contract, the partnership to run PHCs requires an active participation from the State too, and not a “washing hands off” approach to a poorly performing PHC. The role of providing an “enabling environment” for a partnership and the power relations between the State as a senior partner and the NGO as a junior partner have a critical effect on the design as well as execution of the partnership as my experience with KT shows. But, the research to unravel critical success pathways and prerequisites for such policy alternatives in a given context are scarce. Failed PPPs in India (and elsewhere) are many and their untold stories are perhaps as rich as the experiences of ones that succeeded. However, many such innovations and models that work and others that did not, lose their relevance to policymaking in the lack of asking the right questions. In addition, the challenge for India is to be able to develop a capacity for timely and relevant research given that the public health research outputs from India has been poor (Dandona et al 2004) and efforts at conceiving a national policy on health research have resulted in poor drafts (Bhojani et al 2011). With public health research capacity being pitched as an important strategy for India to achieve universal health coverage and the establishment of several national schools of public health over the last few
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years (Reddy et al 2011), we hope that policymakers will get better evidence than that “PPP works or does not work”. Notes 1 Adapted from the birthday speech of Bilbo Baggins in the first of J R R Tolkien’s trilogy The Lord of the Rings. 2 Thor Heyrdahl was a Norwegian zoologist-adventurer who undertook the Kon-tiki expedition crossing 8,000 km across the Pacific Ocean on a raft in 1947, a feat that was previously thought to be impossible.
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