Public Private Partnership

Healthcare – India is a country of tremendous disparities, where the wealthy have access to the most sophisticated treatment options, the poor die for the want of basic ones. The public sector encompasses total 18 percent of outpatient care and 44 percent of in-patient care, whereas the private sector consists of 58 percent of the hospitals in the country, with 29 percent of beds. Treatments requiring extensive recurring expenses, sometime lakhs of rupees per month are now easily available in metropolis, whereas a pregnant woman still dies for lack of access to the basic surgical facilities.

Collaborations, or public private partnerships (PPPs), are becoming the norm in India’s healthcare scenario. The new National Health Policy (NHP) focuses on a larger role for the private healthcare sector. It reinforces its support for PPPs with not-for-profit and private-sector organizations through contracting and strategic purchase of services as a measure to fill the critical gaps in the health system. There is no doubt that the public sector model of medical care as practiced in India has not fully met the expectations of patients. The major reasons for this failure are cogently summarized in the National Health Mission document. Pursuant schemes by the government to overcome these are government initiatives like Ayushman Bharat, regional level initiatives like Mukhyanmantri Amrutam Yojna (MA Yojna) in Gujarat, Bhamashah Yojna in Rajashtan, and Biju Jan Kalyan Yojna in Orissa, to name a few.

Since the launch of Ayushman Bharat, more than four lakh people have benefitted from this. Similarly, the much-famed MA Yojna in Gujarat has now become an established scheme with significant population cover in the region.

Albeit, these schemes are a boon to provide accessible and affordable healthcare services to the masses, with squeezed pricing, cumbersome administrative process with a lot of documentation for processing the bill, and long reimbursement cycle have reduced hospital mergers drastically. Moreover, the drugs and consumables price regulations have further compounded the issue. This in turn has largely affected many healthcare providers, who are finding it difficult to continue providing the desired services to the patients.

With the current trends, it is pertinent to note that the healthcare sector in India is passing through a transitional phase. Gone are the days when healthcare was viewed as a noble profession. Patients demand modern technology and the best care but are not happy about the escalating healthcare cost. The entry of insurance companies offering health insurance had appeared to be the solution to this problem but it soon became a problem in itself. Cashless options added to the service provider’s woes. Simultaneously, the cash-rich corporate companies have also started demanding their pound of flesh by seeking tie-ups, at throwaway costs. The slew of litigations, the aggressive health seekers, judicial decisions, and increasing apathy of the government with its appeasement policies for its vote banks have not helped matters. An even more disquieting factor is that there is a distinct change in the perception of the society regarding the medical profession. Often, professionals involved in the healthcare service delivery are looked upon with suspicion and some degree of hostility. It pragmatically infers to the situation where we find ourselves at this cross-road where it is becoming more and more difficult to provide healthcare in an ethical, transparent fashion and that too at desirable costs.

Gradually, the nobility has lost its sheen and it has been reduced to a profession with tapered thin margins. This while affecting the quality has also brought in severe competition, not regarding delivering the best care, but who can rope in maximum number of patients, and thereby shifted the focus from delivering quality of care, but by the volume-driven sustainability scenario.

Advantages and disadvantages of PPP model
PPP could possibly be the way forward because most government-run institutions pass over lack of operational and monitoring excellence. Due to this, the quality of delivery of cases is not reliable and sustained across the treatment cycle for a patient. Nevertheless, most of the government institutions have excellent doctors, paramedics, and equipment, but in spite of all this, the lack of governance and managerial bandwidth affects overall efficiency and outcome, primarily to provide desirable care to the patients.
However, the PPP model of public and private sector by itselfcan certainly complement the strengths, benefitting the community, across the levels of providing healthcare services to the patients.
While the PPP model does have its own advantages and disadvantages, when the government invites a tender from private players, the one who quotes the lowest gets awarded the order. In such cases, there is a very thin margin and minimal scope with the provider to make it viable.

Access to services
It is a fact that real healthcare challenges lie in Tier-II and Tier-III cities, and there are still no good corporate hospitals in these areas. The dearth of CT scan and MRI services has led to a boom of PPP projects, way back by making radiology services available in government hospitals at subsidized rates, like installation of CT scan machines by a leading equipment company in government hospitals.

It is pertinent that if the government provides infrastructure by way of creating middle-sized higher secondary case hospitals, especially in Tier-II and Tier-III cities, while partnering with private hospitals to provide managerial bandwidth and operational freedom, the community adjacent would get decent healthcare services.

Quality monitoring
While there are established regional and national healthcare brands in India, though with the above changing scenarios, merger and acquisitions (M&A) are happening for business reasons and otherwise. Quality thus unfortunately has not only been fully ignored, it has also taken a backseat in business priorities. In 2005 the government had taken initiative through QCI-NABH to bring accreditation for measuring quality parameters and quality indicators. The quality journey has continued and more and more hospitals still want to have NABH accreditation. To make the same more feasible and penetrative for smaller healthcare organizations, NABH has introduced more feasible quality parameters, especially for entry-level or small healthcare hospitals as to standardize and regulate the delivery model. It is good to note that with this initiative, in a very short time, 828 HCOs and 1318 SHCOs have become entry-level certified and 800 HCOs and 3000 SHCOs are awaiting certification for entry level.

While there has been a drive for accreditation, there is no national standard indicator’s dashboard or benchmark available yet, which could be published as a national dashboard and could be used for assessing compliance and outcome impact with standards at national level. This could provide the ground scenario and actual implementation status with accredited hospitals and would also stimulate the environment of competition as to continuously improve on key components like patient safety, patient satisfaction, employee safety, medication errors, and infection rates.

Outlook
A concerted effort is needed to ensure that the challenge of equitable and fair access to medical care is addressed in India. The present system of providing the most rudimentary services in government sector and leaving high-tech care largely to the private sector is completely unjust.

The central and state government schemes, however well-meaning and necessary, have to be more realistic and not just populist. The payment cycles have to be shortened to prevent interest losses, thus allowing private hospitals to truly partner these initiatives.
It is well worth remembering that private hospitals do not enjoy subsidies or tax exemption benefits and have to buy land, build, and equip them at market price. This puts a great strain on the delivery of services. The government has launched schemes and initiated PPP model of functioning to help the service providers, but these need to be more structured, realistic, and financially viable to make them more effective and attractive.

In a nut shell, the potential for growth in healthcare is huge, provided a fertile ground and stakes are understood and taken care of. Thus PPP can be an effective means of providing rational, affordable, and comprehensive care to the entire population, provided the private partners are also invited to partner in the policy-framing process to their perspective included and emulated particlularly taking care that, the cost of delivering these services to the patients is visible, finally to achieve the true purpose of PPP with a win-win proposition.