At the end of January, I was a part of the first open dialogue between the government of Rajasthan and the private health sector on public private partnerships in the state. The dialogue presented an opportunity to strengthen ties between the two sectors. The dialogue allowed the sectors to define ways to work together and to improve private sector engagement in health. I was overwhelmed to see that engagement between the two sectors had moved beyond passive acknowledgement of one another’s presence to active collaboration on healthcare challenges. At the dialogue, representatives from the public sector, the private sector, academia, and development partners gave suggestions to inform the development of a policy on health public private partnerships in the state.
The Rajasthan government is committed to public private collaborations. The state is welcoming partnerships that advance the key healthcare goals of the state. These goals include strengthening primary care in rural areas, halting the rising burden of non-communicable diseases, and improving the availability of drugs and necessary diagnostic tests. Some collaborative efforts to address these health challenges are in place. For example, the government and the private entity GVK Emergency Management and Research Institute partnered to run the largest emergency transportation system in India. The government partnered with the nonprofit organization Piramal Swasthya to develop phone advisory health services. These two partnerships are testament to advances made in public private collaboration in health. But partnerships between the public and private sectors aren’t easy.
Partnering for Progress is a joint initiative by ACCESS Health International, Inc., and the Max Institute of Healthcare Management at the Indian School of Business. The initiative works toward increasing private sector participation in health. The initiative facilitates private sector innovations to meet public sector demand. The focus is to strengthen the institutional and regulatory framework and to establish transparent and structured mechanisms for private sector engagement within the health system. A strengthened ecosystem will make it easier for all parties to form effective cross sector partnerships. The first step in this direction is to introduce an official state policy for public private partnerships in health. A policy is a way of expressing commitment from the state. A policy also protects the interests of the concerned parties. A policy provides a regulatory and legal framework for operation.
The Partnering for Progress initiative, together with the Wadhwani Initiative for Sustainable Healthcare, facilitated the dialogue between the public and private sectors in health. The dialogue took place on January 23, 2015, at the State Institute for Health and Family Welfare, Jaipur. The main objectives of the dialogue were to identify key healthcare challenges at the district and state levels and to allow the private sector to develop ideas for collaborations that address these challenges. The dialogue also provided an opportunity for participants from both sectors to discuss difficulties in the actual execution of public private partnerships. The dialogue yielded potential solutions for consideration in the formation of the state policy.
The Additional Mission Director of the National Health Mission, Rajasthan, Niraj K. Pawan, chaired the dialogue. District level public officials of the Jaipur Administrative Zone were present to discuss the key healthcare challenges on the ground. The private sector was also well represented by leaders from Piramal Swasthya, GVK Emergency Management and Research Institute, Narayana Hrudayalaya, Manipal Hospitals, Apex Hospitals, the Hindustan Latex Family Planning Promotion Trust, and a few non-governmental organizations.
The district health officials shared some of their largest healthcare challenges. These challenges included manpower shortages at the primary health centers, lack of specialists at community health centers, lack of continuous training and medical education for clinical staff, lack of maintenance at health facilities, improper division of work between clinical and non-clinical activities at the facilities, low accountability, lack of drugs and diagnostic tests at the primary health centers, and a general lack of morale within the public health system. While rather generic across India, these problems require tailored solutions that take into account the geographical and demographic uniqueness of Rajasthan. The desert areas and the prevalence of a large tribal population make it all the more difficult to address some of these challenges.
Dialogue participants engaged in active discussion about each of the challenges. The discussion outlined potential ideas to address the challenges. The discussion sought to gauge the effectiveness of these ideas to solve the issues in question, the cultural acceptability of these ideas, and the potential challenges in the execution of these ideas. Some of the most promising ideas were to split the clinical and non-clinical activities and to outsource the non-clinical work to private companies, especially in the health centers which were running perfunctorily. This solution would improve accountability and reduce the burden of the medical officer who manages the clinic.
The participants also stressed the need for technology. Call centers for health and telemedicine facilities can improve last mile connectivity. Call center and telemedicine facilities must be complemented by regular personal visits from doctors. The private sector can help pilot many of these models prior to their potential launch as a statewide program. The private sector proposed a comprehensive information technology system that integrates all health programs. The private sector suggested that they create a suitable platform to monitor all programs and the outcomes of these programs.
The trickiest part of the day was the discussion of the difficulties of working together and the sharing of ideas on how to address some of these difficulties. As program manager for the Partnering for Progress initiative, I had worked with the government to organize the dialogue. I was quite nervous about whether this portion of the dialogue would be successful. It is easy to move away from constructive criticism to playing the blame game. To my pleasant surprise, the participants showed appreciation and respect for the open dialogue. The government understood the challenges faced by the private sector and sought suggestions for how to ease these challenges. The private sector acknowledged the constraints under which governments work.
Some of the key issues discussed were the need for a dedicated health public private partnerships cell. The cell would be a single entity tasked with overseeing all partnerships. The cell would make it easier for the private sector to approach the government to discuss partnership ideas. The cell would bring more structure into the way partnerships are formed and managed.
The participants identified many other gaps in the current public private partnership environment. These gaps included the need for more transparent and efficient partnership monitoring to ease out payment barriers, the need to resolve grievances within a stipulated timeframe, and the need for experimentation to move beyond short term contracts. Participants also identified a need to use a combination of input, output, and outcome indicators to monitor programs and a need to include the private sector more actively in decision making. Each of the identified needs must be contemplated and executed in a manner most suitable to the public and private parties involved.
The chair of the meeting ended the discussion by summarizing the great significance and challenge of the task at hand. “Health sector problems are so complex that neither the public sector nor the private sector alone can solve them,” he explained. “Partnership between the two sectors is crucial. And yet, like all marriages, this marriage is not easy. It must be built on trust, shared risks and responsibility, and an equal voice for both.”
I believe this dialogue was an important first step toward fostering an environment to engage the private sector actively. A few more dialogues will follow in other administrative zones of Rajasthan before the final public private partnerships policy is released.