India takes pride in the fact that it is one of the fastest-growing economies in the world. But our heads will hang in shame if we look at India’s health system. There is a shortfall of 20% sub-centres, 22% public health centres and 32% community health centres. The average population served by one public sector allopathic doctor is 11 times higher than the World Health Organization’s recommendations. The government spends 1.02% of the GDP on health compared to the global spending of 6%. Clearly, India is struggling to serve its population amid the rising burden of diseases along with poor coverage by public health on the other.
Thanks to such challenges, people are shifting to private medical care which now plays a significant role in providing healthcare. The private sector consists of 58% of all hospitals and 81% of doctors in the country. Similarly, there is dominance of private practitioners for providing outpatient services. With this preference, for private health care services, the out-of-pocket expenditure (OOP) of the beneficiaries has spiked to more than 60%. The excessive reliance on OOP payments leads to financial barriers for the poorest, thereby perpetuating inequalities in health care. In addition to these challenges, the private sector is poorly regulated when it comes to quality and pricing.
The Ayushman Bharat-Jan Arogya Yojna promises to bridge this gap of cost and access through insurance coverage to 10 crore people. In addition, the programme also promises to establish health and wellness centres. This increases the need for additional investment in health where the public healthcare infrastructure remains inadequate. In such a scenario, it has been proposed by the National Health Policy (2017) to engage the private sector strategically in healthcare-deficit areas.
Setting up a public-private partnership (PPP) in health may build our path towards universal health coverage as shown by various PPP interventions worldwide.
I suggest the following key steps to establish a successful partnership:
1.Staunch and well-defined governance: An institutional structure should be set up to foster, monitor and evaluate the PPPs. Although a PPP cell has been established to nurture such models for all the sectors, there is not much movement when it comes to the health sector. A dedicated PPP unit for health under the umbrella of PPP cell will help in effective implementation. This needs to be established at the state-level under the leadership of the state health ministry.
2.Equitable representation of partners in the institutional framework: Institutional structure is a cornerstone for development of a sustainable PPP project. Representatives from both public, private and not-for-profit sector will not only encourage new models, it will also help to meet consensus on shared responsibilities and roles and will facilitate communication among the partners leading to a strong sense of ownership and trust.
3.Evidence-based PPP: Systematic research initiatives and mechanisms must be established to constantly understand the evolving needs and benefits to end users. An overall community health assessment carried out at the district level in consultation with key stakeholders taking into account the demand of users and all sources of health care service delivery available is vital. The need of the community can be broken down to develop individual PPP projects with equal or extra emphasis on primary health care.
4.Regulate user fee: One of the hurdles of engaging the private providers for public health service delivery is OOP expenditure. Therefore, it is important to regulate user fees of this sector under partnership. Some commendable approaches have been put forth by West Bengal and Karnataka Medical Establishments Bill of fixing the rates for private healthcare services. A fee capping of services will balance the profit making business and reduce the health related poverty without compromising the quality.
5.Effective risk allocation and sharing: Risks shall be allocated to the party best able to control and manage them so that value for money is maximised. Because of the risk associated with the partnership the private sector is hesitant. However, the provision of risk sharing will open up the larger window for entry and interest of the private player. Public authority may share the risk by underwriting a minimum level of usage or make payment to the private sector in form of subsidy/reimbursement.
Lastly, the key to success of this partnership is mutual respect and trust with a common goal of providing quality care for all ages at affordable cost. This meaningful engagement may be the next game changer in healthcare for the country.- Hindustan Times