Advancing Partnerships for Universal Health Coverage in India
The third Sustainable Development Goal is to ensure healthy lives and promote wellbeing for all, at all ages. In the context of healthcare, this goal clearly speaks to the achievement of universal health coverage. The objectives of universal health coverage are to provide financial risk protection; access to high quality essential healthcare services; and access to safe, effective, high quality, and affordable essential medicines and vaccines for all.[ref]http://www.un.org/sustainabledevelopment/health/[/ref]
While universal health coverage is where we are headed, here is where we stand today: Each year, one hundred million people become indebted and pushed further into poverty because they or a family member become seriously ill and they must pay for care out of their own pockets.[ref]http://www.who.int/universal_health_coverage/universal-health-coverage-access-pr-20141212.pdf?ua=1[/ref] The goal of accessible, affordable, high quality healthcare is lofty. Effective partnerships that bring together the various market players – the government, the private sector, and others – play a crucial role in the achivement of this goal.
In early October, I was part of a two day workshop on Advancing Partnerships for Universal Health Coverage in India, organized by the Harnessing non-state actors for better health for the poor (HANSHEP) group. HANSHEP is a group of development agencies and countries that seek to improve the performance of the non state sector in delivering better healthcare to the poor. HANSHEP members work together to learn from each other and to share lessons learned with others. The HANSHEP group includes the HANSHEP Secretariat and implementing partners, the Public Health Foundation of India, the World Bank, ACCESS Health International, the University of Delhi, and the International Finance Corporation.
The workshop brought together a mix of central and state government representatives, members of the private health sector and academia, key development partners, and international experts to discuss and explore the need for partnerships between the public and private sectors to support better public health outcomes.
CK Mishra, Additional Secretary and Mission Director of the National Health Mission of the Ministry of Health and Family Welfare, delivered the keynote address at the workshop. Mr. Mishra argued that access to affordable, high quality care was possible only if the care provided through public private partnerships was made sustainable. A healthcare strategy is truly sustainable when a certain set of conditions are met: healthcare services of a certain standard reach intended beneficiaries, the private provider makes enough revenue to sustain him or herself, and the state is able to purchase the services for the long term at a viable cost.
I was heartened that those at the highest level of government leadership were able to view sustainability from the private player’s perspective, as well as their own. In India, out of pocket expenditure is as high as fifty eight percent. Sustainability of care provision can only be achieved by tapping into the strengths of the private sector: technology, know how, well managed processes, and investment capacity. These strengths are particularly relevant in a mixed health system. India has a mixed health system with large number of private players. Eighty to eight five percent of licensed physicians, ninety percent of hospitals, and eighty percent of outpatient clinics in India operate within the private sector, either in whole or in part.[ref] http://www.who.int/bulletin/volumes/91/3/12-110791/en/[/ref] We have a great opportunity to maximize the benefit from the strengths of the private sector by collaborating with it.
The keynote address set the tone for further deliberation on three key issues concerning public private partnerships:
When do we require public private partnerships?
How do we conceptualize and manage a good partnership?
How do we monitor performance and outcomes?
Mr. Mishra highlighted the need for a structure to support collaboration between the public and private sectors. He called for a structure that would enable the fair sharing of investment, risk, and returns between the two partners.
Dr. A. Venkatraman, a leading expert in healthcare partnerships in India, discussed the importance of developing a coherent policy framework in a given state setting, as well as the steps to follow to develop such a framework. Dr. K. Srinath Reddy, the president of the Public Health Foundation of India, offered a novel reinterpretation of the acronym PPP: Partnership for Public Purpose. Mr. Reddy explained that the basis of a partnership should be built on achieving well defined public health outcomes. The public and private partners must keep public health outcomes at the heart of the partnership.
Stefan Nachuk, from the University of California at San Francisco (UCSF) Global Health Group, highlighted the trust building opportunities that come from joint decision making within public private partnerships. Forums such as this workshop encourage open discussion and help build that trust. Mr. Nachuk also offered a helpful perspective on the “lock in effects” of decisions made by governments. Lock in effects are the long term consequences of state determinations on partnerships.
One such commonly debated norm is the L1 rule of awarding tenders in partnerships. According to the L1 rule, the partnership contract is awarded to the private player offering the lowest price. While the state is responsible for spending our tax dollars wisely, the L1 rule often tempts private players to quote lower costs for contracts than are sustainable in the long term. This form of selection is even more harmful when cost is taken as the fundamental criteria, with the government placing little emphasis on performance criteria or health outcomes. Because of potential of lock in effects, making the right choice today and exercizing caution while entering partnerships is crucial.
Each day of the workshop addressed a different focus area in public private partnerships. The first day centered on how to build an ecosystem that is conducive to public private partnerships. A good ecosystem for partnerships must include a policy and regulatory framework that encourages, regulates, and eases partnerships. Day two focused on priorities and good practices in implementing these partnerships. Sessions on the second day discussed practical steps toward better partnerships, how to build monitoring and evaluation frameworks, and what partnerships can do for specific strategic areas, such as noncommunicable diseases and primary care.
The workshop was a great opportunity for us to come together and recognize the immense potential as well as implementation roadblocks in healthcare collaborations. Over the two days of the workshop, we continued to debate the three questions posed by Mr. Mishra. The workshop itself was a collaboration to identify actionable items and next steps to advance partnerships for universal health coverage. In the coming weeks, we will develop a detailed workshop report in which we share the key takeaways from this exciting workshop.
One of the key messages from the workshop was about the lack of capacity in the public sector to engage the private sector effectively to achieve desired health outcomes. Last week, ACCESS Health cohosted a unique course on Managing Markets for Health. This course introduced a framework to help policymakers understand their health systems.
The five day Managing Markets for Health course aimed to build the capacity of policymakers in one important dimension: understanding the market forces at play in their respective healthcare markets. The course introduced a market forces framework. The framework offers a lens through which one can view and understand a complex heath system more clearly. The course presented different strategies that governments and policymakers can adopt, based on the needs of the individual country context.
Come back tomorrow to learn about the market forces framework in the first post in our series on Managing Markets for Health.