a l Planning Work

n sh
a tio op
N on
Public Private Partnerships in the
Health Sector in India

Report
28-105to3

Edited and Designed by Azure Communications, Ph: 9868033799, email: sanghamitra.goswami@gmail.com

Organized by In collaboration with

German Technical Cooperation

National Institute of (GTZ), New Delhi
Health & Family Welfare
(NIHFW), New Delhi
 NationlPgWrkshp
National Planning Workshop

on Public Private Partnerships in

the Health Sector in India

28-105to3,Venu:NIHFW

Co-ordinating Team

Prof. N. K. Sethi

Dr. V. K. Tiwari Dr. K. S. Nair

Shri. J. P. Shivdasani Shri. Pardeep Kumar

Department of Planning & Evaluation

National Institute of Health & Family Welfare
New Delhi
 Contents
Preface .........................................................................................................................................1a-1b

Acknowledgment .....................................................................................................................1c

List of Abbreviations ..............................................................................................................1d

Programme ................................................................................................................................1e

Executive Summary ................................................................................................................1-4

Introduction ...............................................................................................................................5-7

Inaugural Session .....................................................................................................................8

Analytical Summary of Presentations ...............................................................................8-31

Emergent Issues and Recommendations .........................................................................32-33

Conclusion: Future Promises to Keep ...............................................................................34.

Consolidation & Way Forward .............................................................................................35-36

 Pr e f a c e
During the last five decades the Government, at the
Centre and the State, has built up a vast health
infrastructure throughout the country. A large number of
well-equipped hospitals, medical research centres, both in
the private and public sectors, maternity homes located
mostly in the urban areas and a network of rural
dispensaries and PHCs have been set-up to meet the
health needs of the people. Despite this progress,
coverage in terms of health services availability to the
needy is well below expectations. The delivery of health
services in the rural, remote and backward areas, by and
large, is still inadequate and therefore requires a new thrust
and momentum. In order to improve the outreach of
health services in these remote and backward areas, new
initiatives have to be developed, implemented and
sustained. The National Rural Health Mission (NRHM) is
the latest in the series of Government's action
programmes to reach these areas with new frameworks
which would improve the situation in the health sector and
bring in incremental benefits to the larger population. In
this initiative, the proposal of establishing systems for
working with the private sector hold lot of promise since it
would allow government to plug gaps of accessibility and
availability of services for the under-served and un-served
sections of the society.
The Public Private Partnership (PPP) is a new and
essential strategy to extend the scope of the existing health
system in the nation-wide perspective and securing the
willing cooperation of NGOs and social activists for this
purpose. This does not however mean that the
government would abnegate or forfeit its key
responsibilities .The Government in collaboration with
the private sector intends to provide the required financial
and managerial resources for the health sectors in order to
improve outcomes of health investments. Large sections
of the population in this country are faced with a dilemma
of making a difficult choice between the public and the
private sectors. A public service for which they have to
incur opportunity costs, though less expensive, is often
not easily accessible, unresponsive and lacks
accountability, even as the private sector, if available, is
expensive, exploitative and also lacks accountability. It is in
this context that one needs to redefine and reassert the
importance of public responsibility in health services.
During the last three decades there has been a great deal of
criticism of public health services with several studies
highlighting their inadequacies. Most studies on the
problems of health services begin with the proposition
that they are inefficient and unresponsive but without
adequately studying the underlying causes. Often the
Report 1a
approach is to look at the public and private sectors as
independent of one another. The studies on public
hospitals cite inadequate funding, lack of infrastructural
facilities, inadequate supply of drugs and equipment as
important reasons for poor functioning. These are no
doubt important factors with policy consequences but
there are other processes that inhibit public services.
While inadequate funding and infrastructural issues offer
explanations at the level of structure, they do not
adequately uncover the processes at the 'deeper' level in
institutions and society at large in terms of changing
values and norms of personnel and users of services. One
thus needs to locate the analysis of the abdication of
public responsibility in health services at various levels. An
analysis of health status indicators and utilization of
health services acts as a window through which one can
see the many realities in which we live. Greater individual
responsibility and dependence on the private and non-
government sectors, may explain why there is so little
pressure on the state to invest more in these areas. An
important question that needs to be posed is if lack of
quality and limited reach of services is symptomatic of
non-solvency of Government institutions or do we look
for reasons why the state remains important and how it
can be made more accountable to its citizens. For the poor,
the state continues to remain an important player despite
the problems of poor governance, ineffectiveness and its
withdrawal from key welfare areas.
The abdication of public responsibility in health is evident
when one examines the gap in mortality indicators across
social groups, the resurgence and outbreak of epidemics
and the poor and unequal access to basic needs for large
sections of the population. The gap in mortality indicators
between different social groups, viz. scheduled tribe,
scheduled caste and others reflects the extent of
deprivation that exists among the vulnerable sections and
the relative prosperity of the middle and upper middle
classes.
It is in this context, the importance and the need of a
partnership in the health sector becomes important. A
partnership which blends the best of the public and
private sector in a synchronised fashion to meet the
demand of quality services to the remotest and farthest,
both socially and geographically. The middle and upper
classes see the government's role to advocate
privatization, while the poor perceive the State to be
'central to individual and collective life'. Hence, both views
reiterate the importance of State involvement and
challenges some of the assumptions underlying
privatization. The private sector has come in for criticism
because of high cost of treatment, its reluctance to reach
rural areas because of the risks involved and therefore
only catering to selective section of the population.
However, the private sector also brings with it much
needed quality and efficiency. This combined with the
infrastructure provided by the State and its ability to
provide the basis needs even in the rural areas will help in
bringing efficiency, quality, cost effectiveness and
affordability in health services.
The following report on Public Private Partnerships in the
Health Sector underlines the importance of a healthy
Report 1b
public-private partnership and the benefits it can bring
about in improving health services in the country. The
key-word in the partnership being co-operation, inter-
reliance, dependence and mutual benefit. The participants
in the seminar represented members from both the public
and the private sector, with each participant bringing forth
an outstanding issue. This helped to ensure that the
deliberations reflect the views of both the sectors without
any prejudice or bias. It is hoped, through a better
understanding of the challenges such partnerships will
have to face, the report will help in building area specific,
need based, public-private partnerships in health sector.
Prof. N. K. Sethi
Director
Acknowledgement
We are grateful to the Programme Advisory Committee
of the Institute for approving the National Planning
Workshop on Public Private Partnerships in the Health
Sector in India. The Ministry of Health and Family
Welfare has also supported this initiative and provided
continuous guidance in the organization of the Workshop.
Our special thanks are due to German Technical
Cooperation (GTZ), New Delhi, which provided the
stimulation and technical and financial support in
conduction of the workshop. We would also like to thank
all experts who chaired different sessions and provided
valuable inputs during the deliberations.
We would like to extend our gratitude to all participants
who shared their experiences, thoughts and ideas with us
during the three days workshop. Their views and
experiences helped us understand the complexity of
issues being faced in implementation of various types of
PPP models in the country. Our special thanks are due to
State Governments viz. Jharkhand, Karnataka, Rajasthan,
Andhra Pradesh, Gujarat, Delhi, Haryana, Orissa,
Himachal Pradesh, Tamil Nadu and Uttaranchal which
nominated their senior officers to participate in the
workshop.
Report 1c
We are grateful to international organizations like World
Bank and WHO for making the deliberations more
meaningful and substantive by giving their valuable inputs.
We appreciate the active participation by the senior officials
from organizations such as Indian Council of Medical
Research (New Delhi), All India Institute of Medical
Sciences (New Delhi), Faculty of Management Sciences
(University of Delhi), Jawaharlal Nehru University (New
Delhi), EPOS Health Consultants (India) P. Ltd (New
Delhi), Max Healthcare Institute Ltd (New Delhi), Urban
Health Resource Centre (New Delhi), Karuna Trust
(Bangalore), SIFPSA (Lucknow), Janani (New Delhi),
Futures Group (New Delhi), Shaktikrupa Trust (Gujarat),
Achutha Menon Centre for Health Sciences Studies
(Thiruvananthapuram), Holy Family Hospital (New Delhi)
and Dr. L H Hiranandani Hospital (Mumbai), Academy of
Administration (Bhopal), Kurukshetra University and
HOSMAC India Pvt. Ltd (Gurgaon).
All such efforts require a backup of efforts in putting
things together. The workshop was a team effort for
which the faculty and research staff members of the
Institute contributed.
 List of Abbreviations: Pr o g r a m m e
BCC Behaviour Change Communication NIMS National Institute of Medical
Statistics 28.11.05 29.11.05
CHC Community Health Centre
NRHM National Rural Health Mission Inaugural Session Session 1
CBOs Community Based Organisations PPP Initiatives: Diagnostic and Curative
Session 1: Plenary Session Services
NGOs Non Government Organisations
DFID Department for International GOI's Policies on PPP Initiatives in Health & Session 2
Development PHC Primary Health Centre Family Welfare Other Models of PPP: Selected Experiences

Session 2 Session 3
DGHS Director General of Health Services PPP Public Private Partnership
Brainstorming Session
An Overview of PPP Models in India
DOTS Direct Observation Treatment Strategy RCH Reproductive and Child Health
Session 3
30.11.05
GOI Government of India RMPs Registered Medical Practitioners
PPP Initiatives in National Health
Programmes Session 1
GTZ German Technical Cooperation RNTCP Revised National Tuberculosis Presentations by Groups
Control Program Session 4
Session 2
IAP Indian Academy of Paediatrics
Sharing of Experiences on PPP Initiatives by Emergent Issues & Recommendations
SIDA Swedish International
Development Agency States
ILEP International Federation of Anti- Session 3
Leprosy Association Consolidation &Way Forward
SIHFW State Institute of Health and
Family Welfare
IEC Information Education and
Communication
SIFPSA State Innovations in Family
Planning and Services Agency
IMA Indian Medical Association

USAID United States Agency for

MOHFW Ministry of Health and Family
International Development
Welfare

UNFPA United Nations Fund for

MOU Memorandum of Understanding
Population Activities

NIHFW National Institute of Health and

Family Welfare

Report 1d Report 1e
 Executive Summary
A National planning workshop on public private
partnerships in the health sector in India was organized at
the National Institute of Health and Family Welfare, New
Delhi during 28-30, November, 2005. The objectives of
the workshop were to establish a common understanding
of PPP in the health sector, review different models of
PPP in the health sector in India and develop a roadmap
for the design and implementation of PPPs in different
service areas. Nearly one hundred participants, including
senior officials from MOHFW (GOI), officials and
programme officers from States, representatives of NGO
sector, private/trust/NGO hospitals, academic
institutions, representatives of the corporate sector,
research scholars and postgraduate resident doctors
attended the workshop. In addition, experts from
international/bilateral organizations like WHO, World
Bank and GTZ deliberated on various aspects of PPP
which would guide a broad-based policy formulation and
next phase of implementation of the PPPs.
The inaugural function of the workshop was held in the
teaching block of the Institute. The Director of the
institute, Prof. N.K. Sethi, welcomed important
dignitaries and the participants to the workshop at the
function. Dr. R K Srivastava, DGHS in his inaugural
address mentioned that PPPs had existed for a long time in
the country as a voluntary effort but was not structured
systematically to meet the existing challenges. Today
government would not be able to cater on its own the
growing needs of the health sector effectively and
efficiently to meet the Millennium Development Goals as
well as the national health objectives. An active public-
private partnership is essential to achieve programme
objectives and health for all. He added a note of caution by
mentioning that such experiments need to be handled
with circumspection. The current attempts by CGHS to
improve health services among the Government
employees through involvement of private sector had
however fallen short of maintaining appropriate checks. A
sound financial management system to keep a check on
fund out-flows would help in plugging gaps and ensuring
financial feasibility and discipline. Dr. Srivastava pointed
out the case of Rajasthan state in particular, and few other
States as well, where a good number of non-profit
organizations were running PHCs in remote areas
efficiently and had earned public support. Pooling of
funds, skills and resources between government and
private health facilities for using these in an efficient and
effective manner were the key components of PPPs. In
this context, he cautioned that administrative, financial
and other requirements have to be streamlined carefully.
He hoped that recommendations of the workshop would
be useful for implementation of National Rural Health
Mission in the country.
Report 1
Shri. B.P. Sharma, Joint Secretary, Ministry of Health and
Family Welfare, in his address said that public health
infrastructure was extensive yet the spread was thin in
effectively meeting the needs of the un-served and
underserved population. Public health sector's perpetual
problem of inadequate fund was exacerbated by chronic
issues of vacant positions and poor work culture. In this
context, he emphasized the salient role that PPPs can play
in the health sector with special reference to NRHM. The
Mission aims at bringing in qualitative and managerial
efficiency in the health system and in this scheme of
things, it is expected that PPPs would work on the basis of
good planning and design of good contracts to develop a
well-structured health programme for the benefit of all.
Besides this, capacity building, identifying roles and
conditionality of services are necessary aspects of PPPs in
health. Mr. Sharma admitted that the involvement of
private hospitals has led to an improvement in the health
services but problems with regard to billings etc. need to
be addressed. Therefore, clear-cut, strategic and
operational guidelines are essential for the government
and private sector for smooth implementation of PPP
arrangements.
During the plenary session on the first day of the
workshop, Dr. Tarun Seem, Deputy Secretary, MOHFW,
made a presentation on GOI's policies on PPP initiatives
in Health and Family Welfare. He pointed out that
although public health sector infrastructure has a large
network of sub-centers and other health facilities, yet
these fall short of even minimum requirements. The
private sector has grown rapidly and is in a position today
to provide a range of services on competitive terms. The
private sector provides a wide variety of quality services
with varying degrees of qualifications and standards, and
the absence of regulations makes quality assurance in the
private sector rather difficult. Today, a wide spectrum of
services offered in the private sector range from the most
expensive hospitals (meeting tough international
standards) to those which offer cheaper services with poor
quality of care that is comparable to or in some cases
worse than that is being offered in the public sector. Only
few private hospitals use written medical protocols
compared to the practice followed in most public
hospitals. The complementary roles of private sector in
improving access and availability of public health services
to a large population in the country have become a distinct
possibility today. PPP arrangements are still under the
process of deliberations by the government though some
states are running viable PPP schemes which can be
replicated by others. By doing SWOT analysis of existing
PPP arrangements, we may convert potentialities into
realities. A lot of under/and unexplored potential exists
for PPP, especially in rural areas, as there is a consensus
today to accept PPPs in Health and Family Welfare in
both public and private sectors. Shri. T. V. Raman,
Director (AP), MOHFW, who chaired the plenary session,
emphasized the role of PPPs in urban areas where private
sector has had a larger presence. He added that action
points emerging from the workshop would be placed
before the Task Force on PPPs constituted under NRHM,
and these recommendations would provide inputs for the
Task Force on Urban Health as well. A SWOT analysis of
how PPPs work at the macro level would work as a guide in
the implementation of such programmes.
Prof. Peter Berman, the Lead Economist (HNP) of the
World Bank, while talking about characteristics and
principles of a successful partnership, emphasized five
salient points. The first priority issue was to clear the
apprehension about partnership treated as privatization.
The accusations can be cleared up by becoming proactive
in giving a reorientation to the existing role of the
Government health system to match with the
expectations from the private sector. This in no way
suggests that the Government should forfeit its key
responsibility in taking a lead in ensuring health of the
people, of which PPP is an essential strategy. Secondly,
emphasis should be on what is the most effective
way/strategy to improve the outcomes in terms of
coverage, and quality of health services to the poor
population and in the backward areas. Thirdly, we need to
establish a process of dialogue based on evidence rather
than an opinionated version of what works and what does
not. As of now, facts are there but lack substantive
evidence on how to move forward. The emphasis should
be on how to engage in innovations and evaluation of
what to do and how to do it. Fourthly, PPPs should not be
simply understood as a technical area which is limited to
the medical practitioners and administrators. This is a field
in which social, political and economic issues and systems
intersect, which makes it incumbent on promoters of
PPPs to undertake a comprehensive analysis and
assessment before going full steam . It is essential to
develop trust and transparency between the two sectors.
Standing committees at the National, State and District
levels should be created for the design and
implementation of PPP models with fewer directives and
more emphasis on a dialogue process. Finally, we need to
be open minded on technical capacities and
methodologies for PPP development. Prof. Berman
cautioned that the early experiments in the country might
not give hope or successes because of lack of technology.
That however should not deter us from working on
building capacities. In this session, a presentation was
made on an overview of PPP models in the health sector
in India by Dr. Shuvi Sharma of Futures Group, wherein
she presented various models of PPP under different
stages of implementation in various States in the country.
The next presentation by Shri. Deepak Bhandari of EPOS
Group highlighted key determinants of successful PPPs
in health sector which was followed by an open discussion
chaired by Prof.N.K.Sethi, Director, NIHFW and
Report 2
Dr.M.R. Surwade of EPOS Group.
The afternoon session was chaired by Prof. N. K. Sethi
and Dr. H. Sudarshan. It began with presentations of
PPP initiatives in different National Health Programmes
viz. Revised National Tuberculosis Control Programme,
National Programme for Control of Blindness, National
Vector Borne Disease Control Programme, Integrated
Disease Surveillance Programme and National Leprosy
Eradication Programme. During this session, Dr.
Siddharth Aggarwal of UHRC also made a presentation
on the experiences of contracting out outreach services in
Agra city of Uttar Pradesh. In the next session,
presentations on experiences of States in PPP viz.
Jharkhand, Karnataka, Rajasthan, Andhra Pradesh,
Gujarat, Delhi, Haryana, Orissa, Himachal Pradesh, Tamil
Nadu and Uttaranchal, were made. This was followed by
discussions under the chairmanship of Dr. Ambujam
Nair Kapoor and Dr. R. N. Gupta. It was apparent that
given the economy of scale, private sector was ready to
invest in Government facilities for outreach programmes
and qualitative improvements in the implementation of
national health programmes. However, policy to exempt
BPL population and other discriminatory practices need
to be eschewed from any partnership negotiation and
policy decisions. It was suggested to rope in the Third
Party Administrators (TPAs) to establish adjudication
guidelines.
On the second day, presentations on experiences gained in
introducing PPPs as part of the organisational system was
made by various organizations viz., NMMC, Max
Healthcare, SIFPSA, JNU, Holy Family Hospital and EMS
(Ahmedabad). T he session was chaired by
Dr.S.K.Chaturvedi, Prof. A.Venkat Raman and
Prof.M.Bhattacharya. During the next session,
presentations by GTZ, Sree Chitra Tirunal Institute of
Health Sciences, Shakti Krupa Trust (Gujarat), Janani,
HOSMAC India Pvt.Ltd., Kurukshetra University,
Academy of Administration, Bhopal, and IRMS were
made. In the session chaired by Smt. Ganga Murthy and
Prof..P.P. Talwar, the group mainly deliberated on the
mechanisms to bring into play a positive role by private
practitioners in the public health domain. Governments'
role was envisaged in developing guidelines for
implementation and regulation through TPAs. A strict
control by way of financial regulation and budgetary
control was also emphasized for sustainability of the PPP
initiatives. The chairpersons summed up the situation by
emphasising that the stage had come when public sector
was not in a position to deliver health services to all
without exploring the possibilities of taking on board such
partners who could provide more viable and efficient
services. Therefore the role of the PPPs in health sector
was inevitable. To ensure sustainable partnerships, it
would be essential to design all aspects of engagement
which would largely depend on locally available resources.
In this exercise a mapping of health facilities was the first
essential requirement. It was important to examine a
couple of PPP experiments, including such features as
design, funding, management inputs, co-ordination etc. in
order to understand factors that facilitate their success or
failures.
Afternoon session was devoted to brainstorming on
various issues during which major issues and/problems
related to implementation of PPPs, were identified.
Participants were asked to give their opinion on areas
(primary/secondary/tertiary), relationship/expectations,
opportunities, challenges/problems and suggestions.
Feedback received from participants during the sessions
were compiled and presented by the chairperson, Dr. M.
R. Surwade of EPOS.
Following points emerged from the deliberations:
® Partnership does not mean privatization
® Joint monitoring cell, society acts to promote PPPs
® Developing legal framework
® Loan on pattern of industry, timely release of funds
® Involvement of industrial houses
® Flexibility as per need
® Focus on primary health care and prevention of
diseases
® Better recognition to private partners
® Handing over unused/underused infrastructure to
private/NGO sector.
Thereafter, three groups were formed to work on the
following salient issues:
8PPPs for delivery of health services under National
Health Programmes
8PPPs for delivery of diagnostic and curative services
at various levels of health services
8PPPs for delivery of health and family welfare
services in un-reached areas.
The session presentation by different groups was chaired
by Dr. J. P. Steinmann of GTZ and Dr. M. R. Surwade. of
EPOS. The first group emphasized the creation of
autonomous PPP cells with a focus on capacity building
of the private sector and in order to take up the
challenging task of monitoring and regulation. The
second group recommended various innovative schemes
like, introduction of social franchising, social health
insurance and community financing schemes like
Yeshasvini. The third group recommended involvement
of accredited private health facilities at primary and
secondary level through community financed schemes
and inviting private sector to utilize unused/underused
facilities. Qualified practitioners and clinics in un-reached
areas could be identified for providing health and family
welfare services in accordance with fixed rates, to be
calculated based upon expected number of users and
Report 3
payment requirements. Implementation of these
innovative schemes could be taken up on a pilot basis
initially through TPAs and if the evidence was positive,
these could be up scaled, depending on the success or
attrition rate.
The final session, chaired by Prof. N. K. Sethi, led to
consolidation and way forward. Major issues which
emerged during deliberations at the workshop were
synthesised as:
Based on evidence, it is necessary to identify key
®
areas for PPP initiatives in National Health
Programmes, diagnostic and curative services etc.
® Efforts should be made to design partnership
arrangements for long-term sustainability. Working
guidelines for structured partnership, based on
successful experiences of States, MOUs, /contract
agreements, control mechanisms, monitoring and
evaluation, feedback on systems and procedures
etc. which have proved successful should be
documented and disseminated among stakeholders
to be replicated in un-served areas.
® The element of profit making of the private partners
should be accounted for while developing any PPP
model. Provision of output-based incentives to
private sector should rest on the concept of sharing
risks and benefits.
® Feasibility study (SWOT analysis) should be
undertaken through professional bodies before
embarking on any PPP initiative.
® It is important to understand community dynamics
in implementing any health programme. Therefore,
ownership by the community would prove a
clinching factor for sustainability of any PPP
arrangement. Panchayati Raj Institutions and
Community Based Organisations should be involved
in monitoring and evaluation of PPP initiatives to
build credibility and trust.
® State Governments should promote industrial
participation through bodies like the Confederation
of Indian Industries, FICCI and other such
organisations can activate unused/underused
capacity of public health facilities.
® FICCI and other such organisations can activate
unused /underused capacity of public health facilities.
® Appropriate scheme(s) could be designed to rope in
co-operative societies and NGOs to improve health
services coverage through PPPs.
® Bureaucratic procedures are often stringent and
affect the pace of implementation of PPPs in health.
Therefore, it is necessary to simplify administrative
and bureaucratic procedures.
® Costs and economic considerations need to be
considered while designing any PPP model.
Operational cost per unit service at different levels of
 public health facilities may be worked out to decide ® GOI could come out with broad policy guidelines for
price (user charges) per unit of service.
® S t a t e G ove r n m e n t s m a y e n c o u r a g e P P P
arrangements by hospital societies like Rogi Kalyan
Samitis (RKS), Medical Relief Societies (MRS) etc.
Funds collected through user charges may be
Action Points
® Capacity building and sensitization workshops on
PPPs for State level officials may be taken up jointly by
MOHFW and NIHFW. Politicians and policy makers
may also be sensitized about mechanisms and benefits
of PPPs in making Health and Family Welfare a
success.
® PPP units at Central and State level should be made
functional at the earliest. Site visits by the PPP
personnel to such areas and institutions where
successful PPP models are under implementation
would help in organizing similar initiatives. Seed
support should be provided by the Central government
and technical support could be extended by
development partners as per the requirement.
® A cell for promoting PPPs in the country can be
created at NIHFW with financial support from
MOHFW and other donor agencies. It was also
suggested that PPP consultants, under the proposed
National Health System Resource Centre, could
function from NIHFW.
® There is a need to develop a comprehensive policy
framework on PPPs by States. Technical guidance and
support from the Central Government, Donor Agencies
and other technical bodies may be provided to such
ventures which would help them to gain in confidence
and strength.
® PPP schemes under NHPs may be integrated for
better involvement of NGOs/private sector in
undertaking challenging tasks of prevention and
control of various diseases locally by providing state of
art facilities and quality services to the community.
® There is a need to design appropriate, area specific
and flexible mechanisms for accreditation of private
health sector for their involvement in PPPs. Existing
American and European standards may not be
immediately relevant to our programme.
Report 4
leasing out unused/underused infrastructure to private
sector/NGOs under the PPP initiatives. Private sector
needs handholding by the Government to walk the way
with determination and conviction to usher in change
by providing need-based and qualitative services.
® Disputes and redressal mechanism may be evolved
under the PPP initiatives for resolving problems at the
earliest.
® It was also agreed:
8 To send minutes and action points to all participants
for their feedback and further inputs.
8 Participants would inform NIHFW about how their
organizations could contribute to future activities
related to PPP within a period of one month.
8 Participants would inform NIHFW about other
organizations which are actively involved in PPPs, so
that further networking could be made with those
organisations.
8 Participants would send the details of their
presentation which would comprise of the process
followed in the experiment, TOR/MOU signed,
financial details, system of monitoring, assessment
done, factors that affected success/failures and
suggestions for future etc., within a period of one
month.
8 NIHFW would share details of presentations and
related documents, received from States as well as
other organizations associated with the National
Institute of M e d i c a l S t a t i s t i c s, f o r f u r t h e r
strengthening its network and dissemination through
the website of the institute.
8 Constituting a core g roup, consisting of
representatives from major States and organizations,
would facilitate implementation of PPP initiatives.
The core group, with the help of experts, would
further consolidate recommendations emerging
during the group work and carry forward the
proposed actions. Organizations such as EPOS, Max
Healthcare, SIFPSA and GTZ volunteered to be
members of the core group.
Introduction
“We still tolerate appalling inequities between our treatment
of the rich and the poor. Though it may be no more than a dimly grasped
ideal, both medicine and law strive to treat all people equally. In psychiatry, however,
we not only fail to approximate this goal in our practice; we do not even value it as an ideal.”
M any of the problems facing the world-from security
to poverty alleviation and human rights require greater
resources and expertise than Governments are able to
provide on their own. The Government has a huge public
health infrastructure in place and is providing health
services at all levels of the health system. Despite the
existing health infrastructure and substantial expenditure
on health care by the Government, optimum results are
not being achieved. Public resources often fall short of
what is needed to provide universal health care. The
typical incentive system in the public sector may not
always be conducive to expanding access; but improving
quality of care, and ensuring efficient use of limited
funding and expertise in some cases, the knowledge,
distribution networks, or other assets necessary to achieve
a scaled response are found as in the private sector.
Health sector in India in recent years has metamorphosed
from deficiency to enormous changes, in terms of
increase in the number of health care providers and
expansion of coverage of services. The past trend shows
that Government spending in the health sector has
declined from 1.3 per cent in 1990 to 0.9 per cent in 1999
in terms of percentage of the total budget allocations as
well as percentage of GDP. Parallel trends are visible in
the health budgets of various State Governments with a
major share of budgetary allocation for meeting only the
recurrent costs of maintaining existing level of public
health care delivery system. In most of the States, salaries
and wages account for about 75 per cent or even more of
the total health budget. This situation results in constant
shortages of services and facilities, especially in terms of
diagnostic and treatment facilities, non-availability of
medicines, long queues for procedures/diagnosis and
overcrowding in the facilities in rural areas. The biggest
problem is that of accountability of health personnel and
utilization of health and family welfare services by the
underserved and under privileged population.
It is evident that a significant proportion of people
requiring health care seek services of the private sector
and a lot of untapped potential exists in the private sector
for supporting public health initiatives. Given the extent
of private sector dominance in the health care system, it
was felt that any significant improvement in health care is
inconceivable without the active involvement and co-
Report 5
Thomas S. Szasz
operation of the private/voluntary sector.
foundation of a relationship should be built in a manner
The
that the private sector becomes a partner with the state in
order to achieve various public health goals. As a result,
Public Private Partnership (PPP) has emerged as a policy
option for utilization of existing health care facilities and
services of private sector in achieving public health goals
and improving efficiency of resources at the operational
level. The initiative primarily has to focus on developing
strategies to target the under-served areas and
disadvantaged social groups in different parts of the
country. What is most important perhaps is to develop a
system of linkages has to be developed to maximize the
results of the investments in the health sector over a
period of time.
Many types of PPPs have emerged since 1990s when
Health Care Reforms were undertaken as part of the
large-scale structural reforms across the developing
world. 'This was in response to deficiencies in the public
sector provision and in the light of the perceived private
sector strengths of quality and efficiency.' Expectations
were that such partnerships would ensure equity, provide
quality care, create efficiency and encourage coherence
and sustainability of the health system. The nature of
these reforms was diverse, ranging from the private
introduction of mandatory health insurance, to the
contracting of private providers for clinical services, to
the use of private distribution networks for the marketing
of public health care interventions and the manufacture
of drugs and supplies. An increasing interest in the
prospect and potential of PPPs to provide material aid
and social protection can be mainly explained by three
factors-firstly, due to fiscal pressures, Governments (both
at the Centre and State) have to re-allocate the budgetary
resources with utmost effectiveness; secondly, private
providers, both, non-profit or for-profit- play an
important role in social service provision: a role which has
been largely neglected by Governments. For instance,
many studies have shown that more than 80 cent of the
household health care expenditure goes to private
providers running hospitals and maternity homes and
other services. And thirdly, given per the intrinsic, albeit
different strengths and weaknesses of the state, for - profit
and non-profit institutions, the question arises as to what
extent the complementarities can be organised and
synchronized in the provision of health care services. It is
well known that private hospitals do not admit poor and
indigent patients to the required extent as was envisaged
when the land was allotted to them for building of the
hospital. In this context, PPPs are defined as a
collaborative effort, between private and public sectors
with clearly identified partnership structures, shared
objectives, and specified performance levels; and
indicators for delivery of a set of health and family welfare
services in a stipulated time frame. The main objective is to
deal with the problem of poor health services delivery at
two levels- namely, improving accessibility, availability of
quality healthcare services in underserved areas and
increasing mobilization of resources, for health care, from
different sources. Taking care of such embedded
problems would ensure that PPP initiatives would make
even the private sector facilities available to the poor
through reduction in their costs. Greater choice of
services would be available to the poor. It is envisaged that
the synergy between the public and private systems will
reduce the duplication of efforts and wastage of funds. By
developing different models of PPP the specific needs of
the people in states can be fully or substantially met. This
partnership can provide the public with good quality,
high-tech care wherever needed at affordable prices.
Resource mobilization through philanthropy,
subscriptions, donations etc., is easier and more efficient
by creating formal channels of private partnerships in
providing public healthcare.
Rationale for the workshop
The National Population Policy (2000) enunciated by the
Government at the beginning of the century had
recognized the need for increased co-operation between
the public and private sectors in order to achieve the
demographic and population stabilisation goals set out by
the year 2010. Under the Tenth Five Year Plan (2002-
2007) as well, initiatives have been taken to define the role
of the Government, private and voluntary organizations
in meeting the growing needs for health services for
national health programmes especially for RCH
Programme. Fresh guidelines have been evolved by the
Ministry of Health and Family Welfare, GOI, for various
types of health programmes, like the Revised National
Tuberculosis Control Programme (RNTCP), National
Programme for Control of Blindness (NPCB), National
Leprosy Eradication Programme (NLEP), and
Reproductive and Child Health Programme (RCH). The
National Health Policy (2002) recommended
participation of the private sector at the primary,
secondary and tertiary level care and proposed suitable
legislation for regulating minimum infrastructure and
quality standards for health institutions under the new
scheme of things. Under the RCH-II programme, three
key models of PPP, such as social franchising, contracting
in and out arrangements are proposed to achieve
Report 6
improved access to essential RCH quality services in
vulnerable and hard-to-reach areas and making them
affordable and available in vulnerable and hard-to-reach
areas. The recent National Rural Health Mission (2005-
2012) also clearly spells out the need for development of
guidelines for PPPs in health sector and identifying areas
of partnership, which are need based, thematic and
geographically relevant. In order to tap the resources
available for the private sector and to conceptualize the
strategies, the Government of India has constituted a
Technical Advisory Group for this purpose. A reference
frame-work has to be established consisting of officials of
GOI, the State Governments, the national-level NGOs as
important development partners and other stake-holders.
During the last few years, the Governments at the centre
in States have initiated a wide variety of PPP
arrangements. These cover a wide range of options of
contractual appointment of health care personnel for
providing services in PHCs/ CHCs, handing over the
management of public sector health facilities to private
sector/NGOs, contracting for providing a variety of
services in major hospitals, involvement of the corporate
sector, partnership with professional organizations,
CBOs/NGOs, social franchising and social marketing etc.
Varied experiences of implementation and isolated
successes of PPP initiatives in different States suggests
that private sector involvement succeeded in places where
there were well-defined committed groups and clear-cut
memoranda of understanding (MOUs) and these MOUs
were implemented properly. Wherever successes have
been limited the main failures have been attributed to lack
of understanding on both sides, lack of protection
measures and absence of legal back/up for
arbitration/settlement. The limited capacities of the
stake-holders especially relating to skills, archaic
organizational and management procedures and systems
have also contributed to the limited success of PPP
initiatives in some states. However, evidence of increased
competition, delegation of power at the local level and
active participation of the community has had a synergetic
and positive effect on the efficiency, equity, and quality of
health care provision. Hence there is a need for a strong
policy framework supported by legislation at the State
level and adequate financial provision as a prerequisite for
building the right environment for sustainable PPPs. This
should be accompanied by a proper system of
coordination in the delivery of services by different
agencies involved in the programme.
The documentation of successful PPP models and
dissemination process would encourage replication and
help to build confidence amongst prospective partners.
Strategies to rapidly scale up successful interventions to
target the under-served and disadvantaged social groups
in different parts of the country need to be developed. It is
also essential to assess both progress and problems in
implementation of such initiatives and to appropriately
modify the contents according to local conditions well
before deciding the roadmap for implementation. It is also
important to work out suitable models that can actually
deliver and achieve sustainable results within existing
framework. Governments need to be capacitated to
implement and monitor PPPs appropriately since
experiences of working in this area are limited. An
overview of all related issues is necessary to provide
guidelines to policy makers and other stake-holders in
terms of the various dimensions and impact of PPP
initiatives. This assumes particular significance not only in
the light of the changing role of the Government in the
health sector in meeting the national health goals. Given
the above context, the need to establish a strong policy
framework with legislative measures for building the right
environment at the State and Central levels is a
prerequisite for sustainable PPPs. It is also essential to
assess both progress and problems in implementation of
such initiatives at the state level on a continuous basis. The
NIHFW therefore felt this workshop would provide an
appropriate opportunity for a platform for generating a
dialogue on PPP initiatives and issues related to the
implementation. This would also give an opportunity to
assess the role of different stake holders from health
sector for meaningful evidence-based advocacy to build
an enabling environment for development and
implementation of different PPP arrangements and
models in the States. In view of the above, NIHFW in
collaboration with German Technical Cooperation
(GTZ), New Delhi organized a three- day “National
Planning Workshop on PPPs in the Health Sector in
India” during 28-30th November, 2005.
Workshop Objectives
General Objective
To share the current experiences and information on PPP
initiatives in health and family welfare programmes in the
country, draw lessons from best practices of different
States and provide the feedback to policy- makers on
innovative strategies and actions that would facilitate
development of Public Private Partnerships.
Specific Objectives
Following were the specific objectives of the workshop:
8Discuss different forms of the on-going PPPs in the
health sector
8Share experiences and lessons learnt from PPP
initiatives in different States and build on them.
8Deliberate upon strategies and actions for successful
replication of PPP arrangements as a model in other States
8Identify the role of various stake-holders in the
implementation of the PPP initiatives
8Develop a roadmap for implementation of different
PPP mechanisms in the country
Report 7
Workshop Contents
The workshop covered topics such as:
® Government of India polices on PPP
® Scope and forms of PPP in the context of health and
family welfare services in India in a broad national
framework.
® Current status and issues in implementation of PPP
initiatives in different States.
® Experiences of successful PPP initiatives in different States.
® Policy framework and standard operating procedures for
developing PPP.
® Legal and technical issues relating to the development of
a roadmap for PPP.
® Role of stakeholders in PPP initiatives.
®Strategies for replication of best practices.
Methodology
A variety of methods were used to ensure active
deliberation by participants
®Presentation by key speakers in the plenary sessions
®Brainstorming sessions
®Panel presentation and discussions
®Group work
Participants to the Workshop
Senior officials from MOHFW (GOI), and NIHFW
officials and programme officers from States,
representatives of the NGO sector, private/trust/NGO
hospitals, academic institutions and corporate sector
attended the workshop. In addition, experts from
international/bilateral organizations like WHO, World
Bank, GTZ & European Commission also attended the
workshop.
Duration of Workshop
Three days, November, 28-30, 2005
Outcome of Workshop
It was envisaged that the workshop would yield situational
analysis of current status of PPPs in health and family
welfare programmes in the country. Deliberations at the
workshop would also help in identifying gaps and
constraints related to the on-going initiatives and evolve
measures for their replications where such arrangements
did not exist. Proceedings of the workshop would provide
feedback to policy makers on strategies and actions that
would facilitate the development of different types of PPP
arrangements in states.

Proceedings of the Workshop
28 November, 2005 Inaugural Session
T he inauguration of the National Planning Workshop
on Public Private Partnerships in the Health Sector in
th
India” was organized on 28 November in the NIHFW
auditorium. Prof. N.K. Sethi, Director NIHFW,
welcomed the dignitaries and guests. Dr. V.K. Tiwari,
Coordinator of the workshop, in his opening remarks
highlighted the importance of PPPs as an area of growing
interest in India. He said that the workshop was intended
to identify the gaps and constraints and recommend
strategies for better implementation of PPPs. The focus
was on shared objectives and on drawing lessons on PPPs
across States to address the health care provision.
Dr. R K Srivastava, Director General of Health Services in
his inaugural address mentioned that PPPs had existed for
long in the country as a voluntary effort but was not
structured systematically to meet the existing challenges.
The Government alone cannot cater to the needs of the
health sector and therefore private partnership was
essential in achieving programme objectives and health
for all. He added a note of caution by mentioning that
current attempts by CGHS' to improve health services
among the Government employees through involvement
of private sector had however fallen short of maintaining
appropriate checks on the utilization of financial
allocations. A sound financial management system would
help in plugging gaps and keep a check on fund out-flow.
Dr. Srivastava pointed the case of Rajasthan and few other
States as well, where good number of non-profit
organizations was running PHCs in remote areas
efficiently and had public support. Pooling of funds, skills
and resources between Government and private health
facilities for using these in an efficient and effective
manner were the key components of PPPs. In this
context, he cautioned that administrative, financial and
other requirements have to be dealt with carefully. He
hoped that recommendations of the workshop would be
useful for achievement of the National Rural Health
Mission's primary focus on the provision of quality health
care services according to local needs.
Shri. B.P. Sharma, Joint Secretary, Ministry of Health and
Family Welfare in his address said that public health
infrastructure was extensive yet the spread was thin in
effectively meeting the needs of underserved population.
Public health sector is grossly under funded and faces
several problems especially related to chronic issues of
vacant positions and poor work culture. In this context, he
Report 8
emphasized the role of PPPs in the health sector with
special reference to NRHM. The Mission aims to bring in
qualitative and managerial efficiency in the health system.
In this scheme of things, it is expected that PPP would
work on the basis of good planning and design of good
contracts since the primary motive of the private sector is
profit. Besides this, capacity building, identifying roles and
conditionality are necessary aspects of PPPs in health. Mr.
Sharma admitted that the involvement of private hospitals
has led to an improvement in the health services but
problems with regard to billings etc. need to be addressed.
Therefore, clear-cut, strategic and operational guidelines
are essential for the Government and private sector for
smooth implementation of PPP arrangements. At the end
of the inaugural session Prof. K. Kalaivani, Dean of
studies and Head Department of Reproductive Bio
Medicine, NIHFW proposed the vote of thanks.
Analytical Summary of the Presentations
at the Workshop
Session I: Plenary Session
GOI's Policies on PPP initiatives in Health and
Family Welfare
Presentation by Dr. Tarun Seem, Dy. Secretary, MOHFW,
GOI
Chairperson: Dr. T.V. Raman, Director (AP), MOHFW,
GOI
Rapporteurs: Dr. Gita Bamezai and Shri. K. L. Gaba,
NIHFW
The paper reviewed the strengths and weaknesses of the
public and private sector and gave the rationale for the
inclusion of private sector in partnership with the public.
Although India has made a remarkable progress in the
select health parameters, yet in comparison to the world
standards, it still lags behind. India is the epicenter of
childhood mortality in the world today. A look at the
socio-economic condition and health indicator shows that
the poorest 20 per cent in India have more than double the
neo-natal mortality rate than the richest 20 per cent. India
has an extensive public health infrastructure but it falls
short of population norms, needs and standards. Urban
centers are relatively well provided for while rural areas are
underserved. In contrast, private sector infrastructure has
grown rapidly in the last few years and signs are that it will
continue to grow. While comparing and contrasting the
adequacy of public and private health infrastructure, it was
highlighted that even the poor are as likely to utilize
hospital services in the public as in the private sector. The
private sector has been able to set standards by ensuring
their presence at all levels by catering to all sections of the
society, maintaining financial viability with good business
models, good management systems which has allowed
higher efficiency and flexibility to act independently at a
short notice.
The in/outpatient care, in a large measure, is provided by
the private sector, while the public sector suffers from a
critical shortage of health infrastructure and manpower.
According to the population norms, 158792 sub-centers,
26022 PHCs and 6496 CHCs are required today to tide
over the shortage of infrastructure. There is critical staff
shortage of medical and paramedical with an additional
requirement of 880 doctors at PHC, 11191 ANMs, 1869
pharmacists etc. The communicable diseases constitute
the major disease burden but there is a shift towards the
non-communicable diseases as well. Given this situation,
Government has to improve the performance of the
public sector and increase the involvement of the private
sector in meeting the new challenges. Serious resource
constraints make pooling of resources necessary and
public sector benefits from imbibing private sector's way
of doing business. Provision of health care by the public
sector from several competing private providers would
improve the efficiency of the health sector by ensuring
availability of affordable health care to the community and
promotion of exchange of skills and expertise in a broad
framework of PPPs.
The PPPs was defined as a collaborative programme for
synergizing the efforts of the private sector to provide
comprehensive health care facilities. Certain models of
PPP like franchising, branded clinics, contracting in and
contracting out, social marketing, involvement of the
corporate sector, partnering with CBOs/ NGOs, mobile
health vans, health insurance, and public private
partnership were discussed for implementation. The
recommendation to involve one non-profit and one for-
profit actor was given as a way to launch the partnership in
the first phase of implementation. Under the NRHM, the
national level implementation plan lays provision for the
PPP task group to oversee mechanisms and operative
procedures. Hence the recommendation for advocacy
efforts involving national leaders, well-known
professionals and other luminaries to generate demand for
PPPs, mobilizing wide-spread support by ensuring a buy-
in from all national and regional political groups,
bureaucrats, professionals and health functionaries and
establishing quality guidelines, framed with assistance
from professional organizations, were among the many
issues raised by Dr. Tarun Seem in his presentation. The
State and district level implementation plans for
programme management could be taken by setting up a
Report 9
Strategy Development Unit (SDU) as part of the State
Health Society. Priority should be given to development
of PPP initiatives in the high priority districts first and
scale them up to other districts later. Mapping of the
dysfunctional PHCs/ CHCs and private sector could be a
priority area with monitoring and evaluation of PPPs as
one of the important functions of the state society/
SCOVA.
Within India, there are large resources available outside the
public sector that can be leveraged to deliver services to the
poor. The private sector consists of at least 4.5 lakh
qualified doctors and along with the NGO sector, it
currently delivers healthcare with as much vibrant presence
in urban as in remote parts of the country. In India, where
the public primary health infrastructure is already weak and
needs to be strengthened through a massive investment of
funds (estimated at Rs.40,000 crore over the Mission
period), the rationale for investing such funds into models
of PPP should be clear, transparent and open to public
scrutiny at all times. Any successful model of PPP should
be undertaken with all the factors into account. For
example, if the RMPs have to be part of the services
delivery, this scheme has to address realities of the political
economy of rural villages in making the plan work.
True public-private partnership uses expertise,
technology and management practices of the private
sector, but uses public spirit to ensure universal access to
the most desperately poor people.
Chairperson's Comments:
Shri. T.V.Raman, Director (AP) MOHFW, who chaired
the plenary session, emphasized the role of PPP in urban
areas where the private sector has had a larger and
dominant presence. He added that action points emerging
from the workshop would be placed before the Task
Force on PPP, constituted under the NRHM and these
recommendations would also provide inputs for the Task
Force on Urban Health. SWOT analysis of how such
PPPs would work at the macro level would guide
implementation of such arrangements on a larger scale.
Session 2: An Overview of PPP Models in India
Chairpersons: Prof. N. K. Sethi, Director, NIHFW and
Dr. M. R. Surwade, Head, Public Health, EPOS
Rapporteurs: Dr. Poonam Khattar and Dr. K. S. Nair,
NIHFW
Characteristics and Principles of Successful
Partnership.
Presentation by Prof. Peter Berman, Lead Economist,
World Bank
Introductory Remarks:
A number of reports and statistical data published around
1990s mentioned that major load in health sector was
being shared by Non-Government Sector by delivering
services in the range of 50-80 per cent, especially at the
primary care level. Initial response was denial of such
reports as they challenged the common belief of
Government as the only savior. Today, however, we are
converging on this assessment through similar reports by
the Planning Commission. We, as Government and as
Private bodies, must accept today that the emphasis has to
be on more openness and transparency, and ways and
means of enhancing the role of Non-Government Sector
in the health.
Dr. Berman focused mainly on five points which are as
follows:
8Emphasis has to be on partnership and not privatization
since there is some skepticism about PPPs and it is
reframed by many as an agenda for privatization. It is
important to highlight here that it does not imply
abdication of roles of government but re-orientation and
re-assuring provision of public health through private
partnership. Health care in India is already privatized and
the issue is not to talk about more privatization but a
reorientation of the role of the Government. The
Government has the major responsibility to lead and
ensure the health of the people for which PPP is an
essential strategy. The role of NGOs is important and
should be brought into focus both at the policy-making
and the operational levels.
8 The discussion should be driven by a focus on the
outcome of health care system. We should be pragmatic
and not ideologists. Emphasis should be on what is the
most effective way to improve the outcome? What are the
technical strategies we need to improve the outcome? The
question is of coverage, reaching people, and improving
quality of service, cost, and outcome. Linking financial
propriety with programme performance is important
since resources are limited so cost has to be taken care of
in this partnership arrangement. Therefore what can
PPPs do in these areas?
8 A lot can be said on possibilities of PPPs but we need
to drive conversation with evidence and not opinion. As
of now there is a lack of evidence. Though there are ideas
and menus but hard evidence as to how to go ahead is still
limited. The emphasis should be on how to engage in
innovations and evaluate what to do and how to do it?
8 PPP is not simply to be understood as a technical area
alone. This is a field in which social, political, and
economic issues are important. A process of trust and
transparency should be developed between the two
sectors. Launching of various health schemes should not
be seen as a panacea, rather PPP should be seen as a
process to be developed over time. Creation of standing
Report 10
committees at the National, State and District levels
would oversee various aspects of the PPP implementation
and provide orientation as per the local conditions. Basic
approach should be fewer directives and emphasize on
more dialogue among the partners.
8 We need to be open minded on technical capacities and
methodologies on PPP development. We need to work
further on all the technical components which are integral
to PPPs. The early experiments might not be very
successful because of lack of technology and limited
understanding of complexities of issues and functional
aspects of the operative systems. Therefore we should
work on building capacities as a first step.
An Overview of PPP Models in Health Sector in India
Presentation by Dr. Shuvi Sharma, Consultant, Futures
Group, New Delhi
India has shown some progress in basic health indices
today but as compared to other developing countries it is
very slow. There is huge scope and need for improvement.
One of the biggest benefits of PPP is the economies of
scale associated with it and added values of efficiency and
effectiveness.
The fact that over 56 per cent of the rural medical needs
are met by the private sector points to the need of creating
synergies between the public and the private partners.
Flexibility in action is the new mantra. There is no fixed
definition of how PPPs can be established but some
factors need to be kept in mind. These are clearly
identified aims and objectives to be met. A well-defined
partnership structure is crucial for a successful
partnership. Exchange of skills, better management and
wider range of services are some of the benefits
associated with PPPs which would work as one of the
important components of strategies to achieve NRHM
goals.
Some of the models on which PPPs can be based are the
social franchising model - which provides exclusive rights
Sectors
to the local entrepreneur to provide services and
simultaneously undertake risks and chances, as associated
with any business venture. Branded clinics are another
such model with an emphasis on standardized health
services catering mainly to the economically better-off
classes. Models which are sustainable require
standardization of service based on pre-defined terms
and conditions regarding contracting-in and contracting
out. The Government has to take full responsibility for
implementation of terms and conditions to ensure
safeguards against malpractices. Cost can be a
constraining factor initially. Proposals where cost acts as a
barrier can experiment with other innovative schemes,
such as the voucher system to bring down the cost. This
system can replace the need for services and would bring
down the cost. To meet initial costs hurdles donations
from individuals can be taken as a one of the ways of
overcoming initial financial constraints . Partnerships with
social clubs like the Lions club and the Rotary Club can be
established. Involvement of corporate bodies, like FICCI
and other Professional Associations, can also be
developed to off-set initial financial problem. By
establishing such a net of financial partners, the rising
costs can be made more manageable.
Accountability and quality control can be assured through
Report 11
the services of autonomous institutions. These
institutions will bring in regularity of finances and
services. Involvement of different partners requires
accountability as a measure to track the progress made by
both the partners- individually and jointly. From the
patients' point of view finances have to be taken care of as
well. Quality service has to go hand in hand with
affordability. This makes an undisputable case for a well
formulated policy of Health Insurance as rising
expenditures will dissuade people from seeking further
help. A careful assessment of ground realities is required
to select the most appropriate model, which entails careful
evaluation and prioritizing of needs to avoid duplication
of services. A careful selection of partners and scope of
the partnership has to be worked out. For undertaking a
collaborative venture, a foundation has to be built on
mutual trust among the partners without which such a
partnership would collapse.
Public Private Partnerships in Health Care--Key
Determinants
Presentation by Shri. Deepak Bhandari, Chairman and
MD, EPOS Health Consultants (India).
Public-private partnerships (PPPs) have been identified as
a key strategy for progress in achieving the health for all.
The strategy allows leveraging the core competencies
which each stakeholder brings to the table for undertaking
such initiatives which would plug the gaps in the existing
system and make them functional and viable. PPPs are
driven by a dual synergy: on the one hand, government
brings in political legitimacy and transparency, while on
the other hand, NGOs bring in expertise, commitment
and understanding. The resultant businesses bring in
market connectivity and efficiencies.
There are 7 key determinants to PPP in health care:
<. Policies, Legislative Measures and Procedures
<. Institutional Framework
< Communication
< Partner Selection
< Adopting Life-Cycle Approach
< Process Integrity
< Good Governance
Policies, Legislative Measures and Procedures
A comprehensive policy and legislative framework which
clearly defines roles of partners needs to be adopted.
Emphasis should be on developing well tested
procedures, guidelines and contractual arrangements
early piloting of schemes and demonstration projects.
Institutional Framework
Establishment of PPP Cells within the Directorates with
necessary powers and responsibilities to partners and
staffed with experienced professionals will ensure smooth
implementation of PPP. Accreditation and service quality
monitoring mechanism needs to be established. A
regulatory authority with necessary statutory powers
effective and transparent dispute resolution should be
established.
Communication
Creation of avenues for free communication and data
sharing amongst all concerned stakeholders is need of the
hour. Partnership with the media needs to be done on
issues which are of public interest. Effective advocacy and
open communication with the public receiving the
service, any employees affected by the project, the press,
labour unions, potential bidders, financial backers, and any
relevant interest groups is a mandatory requirement.
Partner Selection
If good partners are not selected the PPP initiatives will
flounder with slim chances of being taken seriously by
either partners. It is essential to know- what kind of
experience and track record do the private partner bring to
the project. Will they be able to sustain a relationship
within the terms and over the period of the contract? Will
they be able to manage the opportunities and risks
inherent in the project? It is important that the public
sector partner be willing to retain the risks that the private
partner cannot control, quantify or ensure. It is also vital
that the public partner's administrative personnel have a
sound understanding of PPPs and alternative delivery
methods.
Adopting Life-Cycle Approach
The costing of existing and/or planned public services
must be conducted on a full life-cycle basis. It is
particularly important for the public sector partner to
determine if a project is affordable to the Government.
To this end, the public partner must ensure full life cycle
Report 12
costing at an early stage, taking into account the full cost
of the assets and risks inherent in undertaking a project.
Process Integrity
The process must be fair, open and transparent.
Bureaucratic procedures should not be permitted to
cripple a project. Private partners need a precise
description of what is required and a clear indication of
any hurdles foreseen on the part of the public partner.
The process also requires sound contract management
arrangements, with early identification of the people to be
involved in contract administration.
Good Governance
Planning should be done diligently. The public sector
partner must ensure that its monitoring, regulating and
enforcement roles are recognized and effectively
undertaken
Chairperson's Comments:
In his concluding remarks, Prof. N. K. Sethi spoke about
the vast theoretical knowledge which already existed on
PPPs thereby making a any partnership beginning more
decisive. The need is to actualize these by all stakeholders
by defining their different but specific roles and what roles
the Government, NIHFW and other participating
agencies could perform so that 'we begin the process by a
clear vision of how each one could play a supportive role
in a partnership'
Dr. M.R. Surwade, in his concluding remarks, suggested
few points for consideration to be taken up by all
participants as food for thought.
v Possible areas of collaboration may be explored
v Important cases/what would build good relationship in
PPPs
v Threats/Precautions of PPPs.
Session 3: PPP Initiatives in National Health
Programmes
Chairpersons: Prof. N. K. Sethi, Director NIHFW and
Dr. H. Sudarshan, Hon. Secretary, Karuna Trust
Rapporteurs: Dr. U. Datta and Shri J. P. Shivdasani,
NIHFW
National Programme for Control of Blindness
Presentation by Dr (Mrs.) R. Jose, Deputy Director
General (Ophthalmology), Ministry of Health and Family
Welfare
The programme was launched in 1976 as a 100 percent
centrally sponsored scheme, with the aim of reducing the
prevalence of blindness from 1.4 percent to 0.3 percent in
the Tenth Plan.
Problem -The main cause of blindness is age-related
cataract. This has no medical cure except surgery.
Statistics and achievements-Between 1971-74, the cause
of 75 percent of the prevalent percentage of blindness
(1.38 percent) was cataract. In 2001-02, the percentage of
blind people declined to 1.10 percent and cataract was
responsible for 63 percent of this number. The second
leading cause, refractive error, accounted for 20 percent of
prevalent blindness. In 2004-05, 88 percent of the total
cataract surgery was done through inter-ocular lens
implantation while in 1993-94, this figure was just 3 percent.
Objectives-To provide high quality care, expand
coverage, develop institutional capacity, involve NGOs
and the private sector for de-centralized management
Tenth Plan Development Targets-Besides envisaging a
decline in prevalence of blindness to 80 percent by 2007,
the Tenth Plan has the following goals:
¡ Establish 2000 vision centers in rural areas
¡ Provide 350 additional facilities for inter-ocular
surgery
¡ Establish 50 pediatric units at the tertiary level
¡ Provide 50 non-recurring grants-in-aid to NGOs
¡ Provide 25 non-recurring grants-in-aid to eye banks
¡ Establish 5 new r egional institutes of
Ophthalmology
¡ Train 1200 eye surgeons
Funding-Under the World Bank Project which began in
1994 and concluded in 2004, the NPCB was given a soft
loan of Rs.550 crore to be returned in 35 years. The
financial outlay for the NPCB for the year 2005 was about
Rs. 88 crore.
Methodolog y- Involving the panchayats, local
communities and volunteers, through District Blindness
Control Societies. A major thrust was on collection of
donated eyes and strengthening school eye-screening
programmes.
Point to ponder-Out of 50 eye banks in the country, 40
are located in the NGO sector which have been
functioning successfully.
Integrated Disease Surveillance Project, India (IDSP)
Presentation by Dr. Sunil S. Raj, MOHFW, Government
of India.
The IDSP programme was launched in November 2004
with the objective of establishing a de-centralized system
of disease surveillance for timely and effective action.
Equally significant objective was to improve the efficiency
of disease surveillance for use in health planning,
management and evaluating control strategies.
Report 13
Modus operandi-Surveillance is classified according to
the type of disease in the following manner:
Regular surveillance for vector borne diseases like
malaria, water borne diseases like typhoid and acute
diarrhea, respiratory diseases like TB, other conditions
like road traffic accidents (link up with police computers),
diseases under eradication like plague and international
commitments like the eradication of plague.
Sentinel surveillance for sexually transmitted diseases
like HIV
Regular periodic surveys for alcohol and tobacco
addictions, blood sugar, diet-related problems.
Need for private sector participation-More than 70
percent of patients go to private sector for treatment and
it is widely accepted that private physician is the preferred
first contact. Private hospital facilities are more easily
accessible as compared to the public sector. The network
of professional bodies can be created by roping in big
associations like the Indian Medical Association (IMA)
and the Indian Academy of Pediatrics (IAP). Some of the
salient strategies which can be devised to give short-term
and long-term dividends are:
¡ Selection by volume of target disease attending units
¡ Ensuring Geographical coverage keeping in view
areas not served at present
¡ Credibility and willingness to participate to be ensured
¡ Providing linkages and networking through email,
fax, phone, courier.
¡ Use of Postcards or Index Cards to report unusual
disease trends.
Manpower Deployment Guidelines
1.Role of the health inspector: Health inspector should
supervise the reporting site, visit regularly, help collate
information and provide assistance to the reporting site.
2.Evaluation- Performance indicators
Number of disease outbreaks detected
Number of investigations carried out in response to
disease outbreaks
Number of pre-paid postcards received by DSO.
Points to ponder There is a need to foster respect for the
private sector and highlight success stories so as to do away
with biases.
National Leprosy Eradication Programme (NLEP)
Presentation by Dr. G.P.S. Dhillon, Dy. Director General
(Leprosy), MOHFW, GOI
The Leprosy programme which began in 1955 was given
its present name in 1982 and prevalence of leprosy is less
than one case in 1000 population today. This multi-
partner programme has brought within its ambit
organizations like International Federation of Anti-
Leprosy Association (ILEP) and private medical
practitioners, both of which function within the
framework of NLEP.
Objectives-Strengthening of an adequate referral system
and establishing reconstructive surgery services in
Government Medical Colleges with special attention to
urban leprosy control.
The ILEP is an autonomous NGO and has ten members
working in India in areas that are crucial in sustaining
effective integrated services to leprosy patients. ILEP
agencies run 40 hospitals for reconstructive surgeries to
eliminate deformities.
Funding-The amount of financial assistance being
provided varies with the quantum of work done since in
rural areas assistance is provided on the basis of number
of patients being given POD care while in urban areas the
basis is the population being served by the NGO.
Modus operandi-Private practitioners were trained in
states with a high incidence of leprosy to help in diagnosis
at an early stage and treating it promptly. Besides,
practitioners were to counsel patients on methods to
prevent deformities. Training was provided to
practitioners to deal with patients in highly endemic areas
of seven states.
Public Private Mix in RNTCP
Presentation by Dr. P. P. Mandal, Chief Medical Officer
(Tuberclosis), MOHFW, GOI
TB is a very serious public health issue in India in spite of
large-scale efforts to tackle the disease. The RNTCP was
initiated based on the DOTS strategy which began as a
pilot programme in 1993. PPM model was started in 1995
in Hyderabad; many such projects were initiated locally to
fill gaps in public health system. In other areas, private
providers were engaged to supplement TB services, such
as referral and diagnosis. Experiences and consultation
lead to development of guidelines for collaborations with
NGOs and PPPs, which offered schemes with options to
participate in the referral, diagnosis, and/or treatment of
TB patients, drugs, lab consumables, records and reports
provided by RNTCP as well as financial support. Today as
part of the strategy to build partnership, the RNTCP
provides training and supervision of private providers.
There are five schemes for involving NGOs under the
RNTCP. These are:
Health education and community outreach provision of
DOT, In-hospital care for TB disease, Microscopy and
Treatment centre and a TB unit model. The schemes for
Public Private Partnership include referral services, provision
Report 14
of DOTs, Designated Paid MC (microscopy only,)
Designated Paid MC (microscopy and treatment)
Designated MC (microscopy only) and Designated MC
(microscopy and treatment). Countrywide, all States and
districts are encouraged to involve the private sector and
there are central level initiatives and monitoring to involve all
medical colleges. An example of successful PPP is the
Kannur model where private hospitals and laboratories were
involved as Designated Microscopy Centers which led to a
21% increase in case detection. In the PPM-DOTS
programme the role of the public sector is to provide free
drugs supplies, provide training, detect and treat TB
patients, provide supervision, notify TB cases, retrieve
patients who discontinue treatment and provide funds to
private and NGO sectors. The role of the other sectors is to
refer TB suspects to DOTS, detect and treat TB patients,
share information about patients with public sector, inform
DOTS programme about patients who interrupt their
treatment and to carry out functions as per the private and
NGO guidelines.
The collaboration with the private sector has shown that
PPM-DOTS provides access to better quality of diagnosis
and treatment for patients, less cost to patients and
improvements in productivity and economy. The
programme has shown that mutual trust and respect
between two partners is the foundation stone for the PPM.
To cement and sustain the partnership, continuing dialogue
is the key. However, there are some inherent problems in this
arrangement which need to be attended to. Presence of
heterogeneous and unorganized Private/NGO providers
makes monitoring and supervision indispensable. Successful
running of PPP requires a strong public sector and the
availability of manpower as well as a willingness and an
understanding by the private sector. It was found that there
was reluctance on the part of the private sector to sign
formal agreements with the Government. In medical
colleges/ bigger hospitals, internal referrals from all OPDs
to DOTS centre are sub-optimal and referral for
treatment/transfer of patients remain perennial issues.
These problems need to be overcome.
PPP Initiatives for Prevention and Control of Vector
Borne Diseases
Presentation by Dr. Shampa Nag, Social Scientist, National
Vector Control Programme for Prevention and Control of
Vector Borne Diseases, Directorate General of Health
Services, MOHFW.
With PPP initiatives, NGOs were to involve in remote and
in accessible and out reach areas. Six schemes for partnership
were highlighted.
Scheme 1: Establishment of Drug Distribution Centres
(DDC) and Fever Treatment Depots (FTD)
Scheme 2: Provision of microscopy and treatment services
and referral of severe and complicated fever/ malaria cases
Scheme 3: Hospital based treatment and care of severe and
complicated malaria cases.
Scheme 4: Promotion of insecticide treated bed nets,
insecticide treatment of community owned bed nets and
distribution of insecticide treated bed nets in selected areas
Scheme 5: Promotion of larvivorous fish
Scheme 6: Indoor residual spraying
Level of partners was through local self governance of
minimum 5000 population to 1 lakh population and the
schemes will be implemented as per the policies and
guidelines issued by the Government.
Public Private Partnership for Improving the Health of
the Urban Poor
Presentation by Dr. Siddharth Agarwal, Country
Representative, Urban Health Resource Centre, New Delhi
The health conditions of the urban poor are similar to
those prevailing among the rural population but are far
worse than the urban averages. There is low utilization of
public health services in urban slums and it is the private
sector that is predominantly accessed. Therefore
partnership with the private sector is one of the key
strategies of NRHM in meeting national public-health
goals. Different forms of partnerships, as mentioned in
the National Rural Health Mission, are relevant for
increasing access to health services for the urban poor.
Covering a wide range of services the partnerships have
been designed for contracting the management of the
Urban Health Centre to NGOs, contracting in private
practitioners / specialists for public sector facilities,
providing out reach services, contracting delivery of
health services in un-served areas to NGOs, social
franchising / social marketing, partnership with corporate
sector and formation of community based organizations
under the MNGO / SNGO scheme. When partnering
with NGOs, different methods have been adopted for
ensuring a coordinated effort. In some of the models
adopted, the NGOs manage Government health facilities
for urban slums. This model has been used to manage
health facilities for the slum areas in big metropolitan
cities in several states e.g. Delhi, Bangalore. Or a service
delivery by an NGOs, using their infrastructure under a
government contract as in Guwahati. There is also
collaboration in Government health programmes
(operation of DOTS and Mother NGO scheme) and
informal partnerships with NGOs that facilitate public
sector health services. Examples of such schemes are
found in several cities, like Mumbai, Delhi, Bangalore and
Indore. These initiatives have shown that there is a value
addition to the existing services. These range from quick
expansion of access to emergency child health services in
Report 15
slums, provision of better quality and expanded range of
services, efficient identification and target system, forging
ties with the community to building community capacity
and coordination with different stakeholders and
garnering resources/support.
Part-time outreach services to slums by private doctors
have also been initiated. Other forms of partnerships with
private doctors provide for health services in Government
health facilities on fee sharing/part time basis; specialists
can volunteer for few hours each month. [IPP VIII
Kolkata and Delhi (Arpana)] and Government referred
cases (neonates, obstetric, childhood illnesses) are treated
at private facilities with reimbursement facilities [e.g. TN].
The Government can give “child health vouchers” to
parents of newborns for a series of services that they can
avail of at private doctor's facility [Kolkata, Udaipur].
Another scheme is the once-a-week-OPD subsidy where
private pediatricians (and others) can provide substantially
subsidized services for the poor once a week for a specified
time at their clinics [Meerut, Haridwar, and many other
cities].
Another approach has been forging a partnership with the
corporate sector which helps in supplementing health
investments and services needed to address urban health
challenges. They can also share their expertise pertaining
to demand generation, management and help in the
advocacy programmes for enhanced attention to health of
urban poor population. The PPP experience has shown
that the people are key partners in this process, especially
the slum communities who are essential partners in this
effort to achieve optimal behaviors, penetration into the
most- vulnerable pockets and sustain health
improvements. There are some key challenges which need
to be addressed while implementing PPPs e.g.,
¡ Limited acceptance of PPP approach among public
and private counterparts,
¡ No effective mechanism for identifying the right
NGOs
¡ Lack of experience in developing and administering
partnership instruments (MOUs and Agreements).
There is a need to streamline operational aspects of
partnership and fund release modalities.
Building mutual trust through operational partnership
agreement would sustain public private partnerships. The
capacity building of NGOs should be based on quality
service delivery while the Government should focus on
the management aspects of PPPs. The payment should be
service or performance based. Experience has shown that
maintaining the private partners' managerial autonomy
improves the outcome. PPPs can be an important strategy
for meeting the critical public health challenge of quickly
expanding services and reach to the urban under-served.
Session 4: Sharing of Experiences on PPP < Involvement in Catch up round which is carried out
to improve routine immunization and micro-
Initiatives by States nutrients.
Chairpersons: Dr. Ambujam Nair Kapoor DDG, ICMR
& Dr. R. N. Gupta, Ex. Emeritus Scientist, ICMR.
Rapporteurs: Dr. Vivek Adhish and Dr. K. S. Nair,
NIHFW
PPPs in Health Sector: Jharkhand State
Presentation by Dr. Gopa Kumar, ECTA State Facilitator
Jharkhand
Some of the facts that make Jharkhand a State that is in
need of large scale health care efforts are as follows. It has
an immunization rate of only 9 percent and the Infant
Mortality Rate is 71 per 1000 Live Births.
Infrastructure--In the last 10 years preceding the
formation of the state in 2000, not a single sub-centre,
PHC or CHC has been built.
Programme Coverage --In 1999-2000 Routine
Immunization coverage was only 9 per cent and more than
35 per cent children did not receive any immunization at
all.
Less than 10 per cent of the children aged 12-23 months
are fully immunized that is, they have not been
administered three doses of DPT and OPV, one dose of
BCG and measles vaccine.
Child Health--Eight out of 10 children suffer from some
form of anemia. More than half the children (56 %)
suffer from moderate to severe anemia. In all, among 1000
children born, 78 die before reaching the age of five.
In contrast to the conventional 'top-down' approach,
public and private enterprises in the State have devised an
approach whereby people are made part of the process of
planning, implementation, management and monitoring,
literally putting health in the hands of the people. The
Government of Jharkhand envisions that by the end of
three years (2005-8), each village in Jharkhand will have a
Village Health Committee; each tola will have a trained
Sahiyya. A sahiyya is a woman worker who is trained to
conduct health care activities and generate awareness
about health related problems and health facilities. She
becomes a key health worker who provides timely access
to health and currently there are 55,000 sahiyyas in the
state.
Dr. Kumar made brief mention about PPP initiatives
undertaken in the State:
PPP initiatives of the state to address the problems relating
to health
< Star grading for health facilities, infrastructure
grant up to Rs. 10 lakhs, ambulance for better
mobility
Report 16
< Management of Sadar hospitals
< Involvement in training
< Corporate involvement and funding
< Promotion of indigenous private system for
health care
< Inducting private body for quality control
< A 24 hour health hotline facility
PPPs in Health : Karnataka Experience
Presentation by Dr. H. Sudarshan, Hon. Secretary,
Karuna Trust
The Trust manages 24 PHCs in Karnataka and 9 in
Arunachal Pradesh. The partnership methodology
includes dialogue on consistent basis with people of PHC
area, gram panchayat, zila parishad and upwards.
Objectives
4Developing and testing a model of community health
financing for rural poor.
4Increasing access to public health care by rural poor.
4Ensuring equitable distribution of health care through
social insurance.
4Empowering rural poor for better health
PPP Models
The Narasipur model–This model is based on the
scheme of Community Health Insurance. The scheme
provides for NGO and Government collaboration at
three levels; it envisions developing Community Herbal
gardens for common ailments. Creation of Self Help
Groups, as part of this model, and to encourage the
community to explore alternative sources of financing
that would further assist in establishing micro-credit for
out-patient care. The model provides for pre-paid
insurance for in-patient care, and hospitalization
expenses. This scheme will cover 100,000 SC/ STs
population and 20,000 people living below poverty line.
Bailhongal model–This scheme will be implemented by
Zila Parishad with the aim of covering one lakh SC/STs
population and 30,000 people living below poverty line.
However, it does not cover private health services. The
Insurance cover is Rs. 22 per person per year with costs
shared by the community, milk cooperatives, SHGs and
UNDP. This model provides Rs. 50 to the patient for daily
wages lost and Rs.50 to the hospital for extra drugs per day
of hospitalization.
Some issues of concern which are important in
developing such a model are many. These can be a gap in
implementation, lack of focus on equity and lack of
concern about the ethical imperative. Dr. Sudarshan
informed that corruption is a major hurdle in the
optimum use of services and implementation of
programmes. According to Transparency International's
annual report, India is among the most corrupt countries
of the world with a rank of 88 out of 158 countries. The
health sector is believed to be the most corrupt in the east
and the second most corrupt in an overall sectoral
comparison in the country. Inspections by a proactive
Lokayukta and the presence of a people's forum to voice
suggestions and complaints can check this menace. There
is a need to address corruption immediately in this sector
if PPP experiments are to succeed as alternatives to
inadequate health services.
Public Private Partnerships in TB Control Programme
in Rajasthan
Presentation by Dr. L.P Bhojwani, DTCD (Chest & TB),
Dy. State TB Officer, Rajasthan
Often the first point of contact for majority of TB
suspects is the private sector which makes the role of the
private sector of significant importance in prevention and
control of Tuberculosis in the country. The partnership
scheme would also allow the private sector to supplement
government efforts to control TB. The service delivery by
the private practitioners has to be as per the RNTCP
policy and guidelines. Since the signed schemes are
essential, the service would provide convenient treatment,
observation and efficient facilities for follow-up.
Currently there are 125 NGOs involved in RNTCP, the
number of private practitioners is 246, while big hospitals
and corporate industries' involvement is still under
process.
A larger share of credit for the success in the detection and
provision of treatment facilities goes to Public Private
Partnerships. As a result there has been a marked increase
in case detection rates (Total/ NSP), in the compliance
and cure rates with significant decrease in the default rate.
It was found that the NGOs and private sector
involvement in provision of services was significant in
areas where the government facility of DOT centres were
not available. The default rate of patients at NGOs health
facilities and private practitioners was very low and the
cure rates were around 90 per cent due to good rapport
with patients and the proximity and flexi-time of these
DOT centers. There was an increase in the referrals from
private practitioners to public health facility even for
problems other than TB. In some cases the local RNTCP
had directly approached and involved NGOs and private
medical practitioners successfully. These achievements
demonstrate the ability of the private sector to provide
DOTS. The benefits to the patients include reduction in
Report 17
doctor shopping, decrease in diagnostic and treatment
delays, supply of good quality free drugs, close to their
residence, no costs borne by the patients and improved
compliance-hence less defaulters and better cure rates.
Following factors would help to sustain and take the
partnership farther:
4 Maintaining a high degree of motivation among the
NGOs & private doctors by frequent interaction
4 Increasing the link between the doctors and Govt. Health
facilities
4 Regular supervision and monitoring of private providers
by District programme managers
4 Ensuring “personalized” care for the patient.
4 Measures for accountability of the private provider in
the programme
4 Allowing some degree of autonomy to the doctor
without compromising any of the components of DOTS.
PPP Experiences in Andhra Pradesh
Presentation by Dr. K.Pattabhiramaiah, Joint Director,
Commissionerate of Family Welfare, Govt. of Andhra
Pradesh
Following Public Private Partnership activitives have been
initiated under the FWP:
< Andhra Pradesh Urban Slum Health Care Project
< Aarogya Raksha Scheme
< Private Medical Practitioners (PMPs) in FWP
Sterilization Bed Scheme
<
< Janani Programme
< AP Social Marketing Programme
< EC assisted Sector Investment Programme
< Strengthening of Immunization Programme
< PPP Initiatives proposed under RCH-2
In the AP Urban Slum Health Care Project as many as 192
Urban Health Centres were set up in 74 municipalities with
the objective of providing primary health care to the urban
poor dwellings in slums. The vast potential of the NGO
sector was tapped by contracting 192 NGOs across the State
to manage the UHCs. In the Aarogya Raksha Scheme a
limited hospitalization insurance scheme was devised to
provide in-patient care insurance coverage to the acceptors
of family planning and her/his 2 children. This scheme is
being implemented through the New India Assurance
Company in the State.
About 2707 Private Medical Practitioners authorized to do
sterilizations under the National Family Welfare Programme
have made significant contribution to the FP programme.
Under the Sterilization Bed Scheme there are 2 Government
Hospitals with 40 beds and 18 voluntary hospitals with 290
beds functioning in the State. Under the Janani programme
an immunization booth has been set up in each habitation
with the coordination of ANM, AWW, SHG and Sarpanch
to strengthen the mother and child care programme.
The Government of India started a pilot project in social
marketing programme for promoting temporary
contraceptives through Hindustan Lever Limited, as an
initiative in corporate partnership. Under the European
Commission assisted Sector Investment Programme
(ECSIP) Expanded Sukhibhava scheme is being
implemented to improve institutional deliveries. Under the
scheme, a cash incentive of Rs.300/- will be paid to the BPL
women who deliver in the private hospital. Immunization
strengthening project has been implemented in partnership
with Bill and Melinda Gates Foundation through CVP at
PATH from the year 2001. In the Rural Emergency Health
Transportation Scheme, 432 rural ambulances, called “Mata
Sisu Rakshaks” are being set up and run through NGOs to
transport health emergency cases. As per the GOI
guidelines, two private hospitals in interior areas in each
district are being identified for giving the benefits of the
Janani Suraksha Yojana scheme to the population of the
rural and interior areas.
The PPP experience in Andhra Pradesh has shown that
the following guidelines should be kept in mind for PPP
implementation:
Track Record- Reputed NGOs who have good track
record and have proven experience in providing health
care facilities may be selected.
Close Monitoring-In addition to the departmental
officers, coordinators cum supervisors, preferably retired
medical personnel and those with field experience in
providing health care facilities, can be inducted for
supervision and monitoring.
Cost Sharing-Expenditure incurred on running the
administration can be shared by the Government. This in
a way would encourage and motivate the NGOs to
become partners without fearing about much investment
from their side on administrative costs.
Public Private Partnership Initiatives of Government
of Gujarat
Presentation by Dr. Vikas K. Desai, Additional Director,
Health and Family Welfare, Gujarat
During her presentation Dr Desai highlighted various on-
going PPP inititatives in Gujarat
PPPs and funding -The Number of hospitals receiving
grants-in-aid from the Government- are 94. The amount
varies between 25 to 90 percent depending on the location
of the health facility or the project site. Some unique and
innovative partnership schemes, like Polio reconstruction
surgery and outreach services through camps have been
received well and provided adequate coverage.
Report 18
PPPs under Blindness Control Programme -NGOs and
the private sector have been pillars of success for the
national programme for control of blindness in Gujarat.
About 1740 NGOs involved in this venture have
performed 60 percent of the total cataract surgeries which
is a good index of the scope for such collaborative efforts.
Community participation - Studies conducted by State
colleges show that use of Government services by the
community, like women workers of dairy co-operatives
aiding in information dissemination has been a success.
Other NGO services
8 Gender sensitization and advocacy
8 Social marketing of contraceptives making them easily
available
8 Social marketing and easy accessibility of ORS
8 Informing people of adverse consequences of sex
discrimination and abortion.
Schemes-Under Samaydan, 125 specialists have been
approved as part- time specialists in rural hospitals and
Vande Mataram Yojana provides free ante-natal clinics.
It would appear that PPP has made available greater
infrastructure and hence wider accessibility in the state to
run the full course and take up more challenging ventures
with the Government.
PPP in Health Sector (Family Welfare), Delhi
Presentation by Dr. Kirti Bhushan, CMO (NGO
Scheme), Delhi
DFW has partnership in following fields:
RCH Programme, Pulse Polio Programme, Immunization,
Sterilization Bed Scheme, UFWC, Health Post and Post
Partum Units.
Objectives to be met through this partnership are-
4Training of manpower
4Availability of services in un-served and under- served
areas
4Accessibility of services
4Provide quality services
Need for NGO participation -
< NGOs have a wider reach among marginalized and
disadvantaged people in the state.
< NGOs have a distinct advantage of an understanding
of socio-cultural and economic status of the local
population.
< National Population Policy 2000 lists participation of
NGOs as necessary to achieving the goal of 2.1
percent TFR by 2010.
State Schemes introduced by the Department of Family
Welfare, GOI
v Under the Mother NGO scheme (MNGO) -
introduced by the Department of Family Welfare in the
Ninth five year plan, MNGOs are selected and allocated
one/two districts to implement the RCH programme.
v MNGOs in turn select smaller NGOs, called Field
NGOs, which compliments and supplements
Government health services.
Under the MNGO scheme, the flow of funds operates
from the Centre to the State RCH society and then pass on
to the MNGO and from there to the Field NGO. An
amount of one lakh is given in the preparatory phase for
CNA/Base line Survey, identification of Field NGOs and
preparation of consolidated project proposal. A total of
5-15 lakh rupees annual allotment, per district is made,
depending on the number of Field NGOs ready to work
in the designated area. Apart from other funds, MNGOs
can retail 20 percent of the total project costs as
administrative costs. The monitoring system is based on
observation and physical verification of records. MNGOs
submit financial and physical report to District RCH
society besides officials from the Department of Family
Welfare make periodical visits to assess their work. On the
request of the State, independent agencies like CAPART
can be involved in an assessment of State specific
problems. Most of these schemes are for the rural or
district level areas. In Delhi, however, only 10 percent of
the population lives in rural areas. Therefore, there is a
need for a separate scheme for Delhi. and this should take
into account the fact that 90 percent of the population is
urban. Placements of a Regional Director and State-NGO
Coordinator are provided for but these posts have been
vacant ever since the inception of the scheme.
Measures for efficiency
t Periodic meetings between officials at the State and
Central levels.
t Timely flow of funds to NGOs.
t NGO staff to be trained periodically in correct
vaccination techniques and maintenance of cold
chains.
t Adequate logistics to carry out routine welfare
services like, syringes and weighing machines
t Mobile Health Schemes- mobile dispensaries, a
certain number, per assembly constituencies. The
Government provides medicine while the NGO
provides staff.
VIKALP: A PPP Experience of Haryana
Presentation by Dr. Sanjay Bhardwaj, Consultant,
Department of Health, Haryana
Report 19
Objectives-To provide quality Primary Health Care Services
and make them easily accessible to the poor of Haryana.
The funds from the State Health Society flow down to the
District Health Societies. The programme provides for
identification of suitably equipped private nursing homes
and designates them as partners in provision of services.
Selection of a right partner is imperative for a successful
PPP. In developing PHC service packages, including
referral control and fixing their cost with private providers
was an essential aspect of the Haryana experience.
Another focus area was to provide good quality and low
cost essential medicines, contraceptives, vaccines and low
cost diagnostic services to the poor. Setting-up a good
supply chain for carrying out these programmes is the
next essential step. This aspect of the chain is often
overlooked by people, hence identifying suitably equipped
private nursing homes, hospitals and designating them as
partners would be the next step in this initiative.
Developing PHC service packages including referral
support and fixing their costs with private providers is
essential to plug the loopholes in the coverage and
provision of adequate services. Efficiency and quality
control are two important planks of a successful PPP
initiative. Therefore development of an efficient system to
monitor the program implementation in terms of
coverage, quality of care and efficiency is vital. The
funding mechanisms which are the lifeline for sustaining
the scheme need careful attention. The funding system is
based on a top-down approach in which funds from the
State Health Society flow down to the District Health
Societies. A revolving fund created with each Department
of Health and Family Welfare/ Civil Surgeon, based on
estimated quarterly expenditure, has been established for
this purpose. Replenishment of the revolving-fund based
upon service utilization data complied and checked by the
District Health Coordinators is also carried out. The
District Health Coordinators are responsible for
processing the invoices and claims from the PHPs and to
facilitate payments by the DH&FWs in a timely manner.
This ensures added responsibility as far as financial
matters are concerned.
Public Private Partnerships in Orissa
Presentation by Dr (Ms) Sabita Mishra, Addl.Secretary,
Department of Health & Family Welfare, Govt. of Orissa
There are important reasons that necessitate a public
private partnership in the state of Orissa. It will help in
sharing the responsibility by the private sector for health
care service with a focus on disadvantaged population.
The private sector would augment and complement the
Government's efforts in the sector. It would also create
and sustain a replicable model in different parts of the
State and can be used in different programmes to increase
efficiency and accessibility.
The instruments for PPP in Orissa are based on MOUs,
work plans and evaluation systems. Establishment of a
State PPP-NGO Cell and District PPP-NGO cell would
ensure better co-ordination since there is often a lack of
co-ordination between the state and the districts.
Public Private Partnerships in Himachal Pradesh
Presentation by Dr. Gian Chand, Principal SIHFW,
Parimahal, Shimla.
Certain PPP initiatives in the State have demonstrated the
viability of such collaboration. These include outsourcing
of training of paramedics and nursing, sub contracting,
outsourcing information, education and communication and
RNTCP and partnership. Multinational non-governmental
organizations were involved in HIV/AIDS programmes,
RNTCP and in Blindness Control Programme. 10 private
health institutions outside the State and 9 within the state
were identified for the purpose of reimbursement. The
areas/services identified for PPPs are provision of
diagnostic facilities in Government Health facilities, medical
and paramedical education, management of emergency
transport and management of non-functional institutes.
PPPs in Health and Family Welfare in Tamil Nadu
Presentation by Shri. Muniappam, Demographer and
Shri.K. Krishnamurthy, Statistical Officer, Directorate of
Family Welfare, Govt. Tamil Nadu
How the partnership spans out
Types of services - Out-patient service is handled by the
private sector and the in-patient, preventive,
immunization, family welfare and delivery services are
handled by the public sector. The Governments'
contribution includes co-opting the private sector in
increasing health and family welfare service coverage.
The belief that involvement of the private sector
complements the implementation of Government sector
health programmes has gained currency. About 1419
private hospitals are approved for performing vasectomy,
tubectomy, MTP and other contraceptive services in the
State. The Government covers the drug cost of the
sterilization acceptor and gives bed grants to NGOs for
sterilization services. Urban family welfare centers run by
voluntary organizations are also given similar grants. The
private sector cooperates by hiring services of private
sector anesthetists and obstetricians for Government
hospitals and PHCs when Government specialists are not
available. Private hospitals and NGOs are allowed to
organize eye-camps and accreditation of private hospitals
also ensures confidence. Financial allocations are shared
for certain category of services through special schemes
covered under the Prime Minister's and Chief Minister's
relief funds. In total 90 PHCs have been adopted by
private industrial houses for maintenance. Some private
hospitals station ambulances with para-medical workers in
accident prone road stretches. The Government out-
sources cleaning and laundry services to the private sector
and employs drivers for Government PHCs.
Report 20
Conditions for the Private sector
Maintenance of proper records of surgery details and
submission of the monthly report to the district
committee are emphasized as essential prerequisites for
financial assistance. An institution is recognized as an
approved institution for surgery by the District Collector
on the recommendations of the District Committee. The
number of institutions that have been approved in the
State has increased by 51.1 percent between 1998-99 and
2004-05. There has been a quantum jump of 66.8 percent
in the number of sterilizations performed by private
hospitals during the same period.
If a malpractice is noticed in the provision of family
welfare services, the District Committee visits the private
health institution to make recommendation to the DC for
de-recognizing the institution. For effective and reliable
services creation of a monitoring cell at the Secretariat to
assess the functioning of the PPP has become inevitable.
PPP Initiatives in Uttaranchal
Presented by Dr. C. P. Arya, Addl. Director, Directorate of
Medical Health & FW, Uttaranchal.
The Goverment of Uttaranchal had initiated the PPP
arrangements for the following services in the State:
s Privatization of laundry and waste management
s Introduction of mobile clinics
s Eye care camps
s Blood bank establishment
s Health care delivery in tribal areas
s MNGOs for RCH
s PCO in Govt. health facilities
s Setting up laboratories, particularly for BPL population
PPP Experiences in West Bengal
Presented by Shri. Rajesh Jha, Vice President EPOS Health
Consultants (India) Pvt. Ltd, Kolkata
Under the guidance of EPOS four PPP experiments have
been taken up for implementation in the State of West
Bengal since last three years. Before initiating these
schemes rapid assessment of local needs was done and
EPOS was involved in the capacity building at State and
district level. These initiatives have laid the foundation for
up scaling the efforts under the various PPP models in the
state.
Remarks by Chairpersons:
It emerged from the discussion that given the economies
of scale, private sector is ready to invest in Government
facilities for qualitative improvements. However, the
policy to exempt BPL population and other discriminatory
practices may not work well. Rather, flexibility is needed in
the implementation of PPP models. It was suggested to
rope in Third Party Administrators (TPAs) to avoid the
risk of non-compliance and defaulters.
29 November, 2005
Session 1
PPP Initiatives: Diagnostic and Curative Services
Chairpersons: Dr.S.K.Chaturvedi, Jt. Director (CGHS),
Dr. A. Venkat Raman, Associate Professor (Univ. of
Delhi) & Prof. M. Bhattacharya, HOD, Deptt. of CHA,
NIHFW
Rapporteurs: Dr. U. Datta and Dr. V. K. Tiwari
Privatization initiatives at Navi Mumbai Municipal
Corporation.
Dr. Akash Rajpal, Manager Medical Services, Dr. L H
Hiranandani Hospital, Mumbai
The Navi Mumbai Municipal Corporation's initiatives
have had a successful run despite the risks involved in a
new working system based on partnership. NMMC has
outsourced the Departments of Sonography and
Radiology, housekeeping, ward-assistance and procuring
linen on rental basis. NMMC also leases out part premises
for multi-specialty Private Hospital and Specialty
Diagnostic Services to Hiranandani Healthcare Private
Limited.
The reasons for outsourcing Sonography and Radiology
departments are enumerated here:
4 Inefficient sonography and X-ray services at First
Referral Unit.
4 Failed and defunct MCH USG Section.
4 Recurrent maintenance costs.
4 Lack of responsibility by user.
4 Requirement of sonography services at the MCH
centers.
4 Need for upgrading the technology.
The salient points of the PPP initiatives are transparency
and competitiveness; one of the mechanisms utilised is
the use of tender for the selection of the contractor and an
agreement copy is given prior as part of the tender
document. All NMMC radiology staff from the MCH is
absorbed at FRU for better efficiency and utilising the
existing capacity. Payments are made to the contractor for
free patients also and NMMC is free to decide its own rates
to be taken from patients. It is a long-term contract and
patients have to come only through the NMMC cash
counter. The rates availed in this contract are 7 to 10 times
less than the market rates. The operator gets higher rates
outside working hours for emergency services and penalty
is imposed on the operator for uptime less than 98 per
cent. Contactors get compensation for lower turnout and
NMMC gets incentive for higher turnout. The contractor
Report 21
breaks-even within 2 years and the onus of errors is on the
contractor. The SOP sets out demarcation of
responsibilities for smooth functioning of all the terms
and conditions.
The benefits of this PPP are:
4Higher turnout of patients.
4Zero investment and generation of income.
4Fulfilment of service commitment.
4Availability of services within the hospital.
4No recurrent costs and affordability of services.
4Self-sustaining system.
Challenges faced in this PPP scheme cover a wide range of
issues like, convincing the corporate body of the
prospects of partnership as a business proposition, co-
opting of earlier contractual staff becomes a compulsion,
pressure of labour union on the professional agency and
NMMC. For quality control, continuous feedbacks from
referring consultants and audit by the external radiologists
and imposition of penalty clauses on errors in reporting
must be ensured to make the partnership run successfully.
Presentation on Max Healthcare
Dr. Shubnum Singh, Adviser, Max Healthcare, New Delhi
PPPs are advantageous and lead to operational gains and
better public services by ensuring that better or more
service is delivered for the same price. Operational gains
are achieved by focusing on outputs as opposed to
processes. Diverting departmental resources on strategic
management provides strategic clarity, ensuring that key
services are delivered effectively. The critical balance to
ensure success can be achieved by focusing on the
concrete, specific, and not only a common vision or
shared aims. Sharing of risks and rewards, governance,
flexibility of different models, and patience in time-frame
are key factors in any PPP. The element of distrust should
dissolve and be replaced by an element of trust between
the partners.
Among the partners the vision may be common but
objectives may not be the same always in an arrangement
where partners have different perspectives. To keep the
collaboration intact, being flexible and open in thought-
processes is a pre-requisite for the PPPs. The dialogue and
implementation is a very time-consuming process hence
the expectations should be vivid and clear and the onus
should be shared (be it the corporate sector or the NGOs)
by solving the problems equitably. The traditional
approach should be done away with by adopting the new
approach of being patient-centric. The policy should be to
design, develop and implement together. The root causes
should be identified, addressed transparently and
individuals from grassroots should be involved in the
decision-making. Keeping clear-cut guidelines on product
delivery and terms of payment need to be well defined.
How to make a PPP sustainable? An exit-policy is required
for private players if the scheme is not successful. To
sustain any PPP, it should be ensured that there are clear
guidelines on operative systems, and issues of
accountability, transparency and deliverables. Lack of
trained and motivated manpower are the impediments in
making the partnership work.
There should be shared governance and responsibilities.
Some of the Government's responsibilities in Max health
care are:
< Real estate and utilities (electricity, water and
telephone).
< Procurement and timely supply of medicines.
< Sole responsiblity for the supply of vaccinations.
Any other Government sponsored programmes for the
general public, for example, DOT scheme for T.B., Polio
etc. will share all infrastructure costs and operating costs
with Max India in a 50:50 ratio.
The responsibilities shouldered by Max health care are:
Supervision of all medical personnel .
< institutions get transformed into purely commercial
Staffing/ recruitment and management of clinic.
< Dispelling myths and misconceptions associated with
Coordination with Government of all clinics and the
< construction, running restaurants banquet halls and
laboratory.
Maintain the look and feel of the clinics.
< be extensively used to publicize health facilities. Panchayat
Share all Infrastructure costs and Operating costs with
< was not fulfilled either.
the Government in a 50:50 ratio.
< Visits by specialists on rotation to all clinics, on need
basis.
PPPs in RCH- SIFPSA Experience
Presentation by Dr. S.Krishnaswamy, General Manager,
SIFPSA, Lucknow
SIFPSA seeks to facilitate, through innovative means and
partnerships with government and other agencies, the
goal of health for all by improving the quality, demand,
access and delivery of family planning and MCH services
and also improving related quality of life parameters
including the status of women. SIFPSA emphasizes on
the CBD approach. The CBD approach is electing a
women volunteer from the community using a set criteria
and equipping her with knowledge and skills to provide
non-clinical FP and RCH services at the door steps of
clients. For selecting an NGO as a partner there has to be a
foolproof process. The selection criteria involves the
NGO information sheet, desk appraisal, recommendation
from DM/CMO/donors, field appraisal, joint proposal
Report 22
development, presentation before PAC, sanction of the
Project by ED, signing of project agreement. At this stage
the project is set to be launched.
The monitoring and feedback system at the district and
State levels is imperative for sustaining the efforts and
providing on the spot solutions to any bottlenecks in the
process of implementation of the scheme. If on one
hand women empowerment, use of folk media -
education through entertainment are issues to be
addressed, on the other hand coordinating with the public
sector is still a big challenge. The benefit accrued have
been of establishing partnership with over 150 NGOs by
awarding over 275 projects and 16,500 additional family
planning volunteers have been created to be used for
extending the reach of services. However the challenges
faced by the project are many and significant among them
are the mechanisms of reaching the SC/ST/minority
groups in a more effective way, co-ordination with public
sector, program sustainability after projects.
The lesson learnt through this partnership is the overall
reiteration of the private sector's role in enlarging the
scope of public health services and in increasing the CPR.
It can effectively supplement the public health system and
also contribute to women's empowerment by creating
opportunities for taking up responsibilities as depot
holders and increasing demand for FP/ RCH services.
contraceptive use can be undertaken by using the cadre of
volunteers formed under this partnership. The folk media
like nautanki, quawwali, birha, magic and puppetry should
members should be trained and inter-personal
communication training should be provided at the
grassroots level.
The PPP's outcomes have been:
< Out of 36,500 C and D category villages 27,321 have
stocked either condom or pills.
< Incremental rural sales of 148 million pieces of
condoms and 2.18 million cycles of OCPs in 4 years
have been achieved.
< Cost effective project-Rs. 109/-per incremental
couple year of protection.
PPPs at Tertiary Sector: Some Observations
Presentation by Dr. Sunita Reddy, Asst. Prof., CSMCH,
JNU
In this presentation the emphasis was on maintaining the
balance of power between the two sectors private and
public. Following observations were made about the
present status of the partnerships in Tertiary Health
Sector:
<The private sector has been getting subsidies on land,
water and electricity, and concessions on import duty on
diagnostic equipment. The only condition was that they
should provide 30% in-patient facilities and 40% of the
out-patient/ diagnostic services free of cost for people
below poverty line. The Tenth Plan went further ahead in
offering more concessions to private hospitals in import
duties, loans from public finance companies, and the
status of industrial activity for earning foreign exchange.
<Insights from Qureshi Committee report however
highlighted some deficiencies of this arrangement. One
of the salient issues related to the inadequate and erratic
practice of existing free treatment facilities. The problem
persists because there is no precise definition of 'poor' and
'free treatment'. The promotional tag of efficiency does
not hold because of the high cost involved.
<There are two perspectives on the partnerships between
private and public sectors in health. First, the business
point of view- where quality and quantity of service is
subservient to least costs and maximum profits through
curative activity. Secondly, it defines public gain as the
essence of partnership.
Some violations have also been reported. The officials
agreed that, over time, most of these trust and charitable
ventures. Violations like subletting the land and building
for commercial purposes, encroachment, unauthorized
offices etc are common norms. The main violation was not
fulfilling the 40% and 25% quota of treating the poor
patients. The quota of providing free facilities to patients
Are Public Private Partnerships in Health Care Possible?
< PPPs are possible when both the sectors genuinely
commit themselves to a common goal.
< The soft and permissive attitude towards private sector
in tertiary care ensures that integrated Primary Health
Care remains a far cry.
< Institutions should have either differential fee structures
through in-built cross subsidies or provide free care to the
poor.
< State demand that mutual give and take strategy; pooling
of information, standardization of therapeutic strategies,
and cost of treatment for common diseases, specially those
covered under the national program, would have to be
compulsory
The recommendations are that proper regulatory
mechanisms and monitoring for both private and public
sector institutions and self-regulation within private sector
are necessary. The positive experience of some of the
PPPs in different States can be taken as examples for
replication.
Report 23
PPP Initiatives of Holy Family Hospital, New Delhi
Presentation By Rev. Arthur R. Pinto, Director, Holy
Family Hospital
It was articulated that the pre-requisites for any PPP would
be a combination of 4 Cs, which are communication,
consultation, coordination and collaboration. The areas in
which partnerships can be explored are community health,
hospital services, education, training and research. These
areas have been covered broadly as under:
u Community Health
The Delhi Government has allocated Mobile Health
Clinics in 12 slums and immunisation programmes are run
in the hospital and slums as part of the community
outreach programme. MCH Care, health education, home
visits, counselling, pulse polio programme and polio
surveys, referral to Government centres for treatment can
also be part of this scheme to ensure a successful PPP
initiative.
u Hospital Services
Free care for the economically backward and Motiabind
Mukti Abhiyan Cataract Surgery and Medicines have been
taken up to ensure the success of the PPP.
u Education
Short Term Training Programmes are ways of sharing of
teaching and learning Sessions. The Nodal Centre for
Training in Medical Bio-Waste Management is being
provided to all partners.
u Research
Research titled, 'Children of India' has been carried out in
a collaborative mode with other research institutions like
AIIMS, WHO, UNICEF and few other hospitals and
bilateral/UN agencies.
The future plans are:
At the invitation of the Mewat Development Agency
there are plans to open Rural Health Centres in
< Badshapur -7 kms from Gurgaon
< Sohna-20 kms from Gurgaon
< Nuh- 45 kms from Gurgaon
These would be connected to a 100 bedded hospital in
Gurgaon. The vision of taking health care to the masses
extends to provision of free-care to the economically
backward classes.
The vision of taking health care to the masses extends to
provision of free-care to the economically backward
classes.
Emergency Medical Services, Ahmedabad
Presentation by Dr. Haren Joshi, EMS, Ahmedabad
Mortality due to Road Traffic Accidents is 7 times more in
developing countries like India where there is no
organized Emergency Medical Services. The essential
factor for EMS is that both the public and the private
sector should work cohesively. The goal is to make all
hospitals participate in EMS by implementing the scheme
which provides for picking up of a person from the
accident spot and giving primary life saving care free. The
reason for the success of the independent EMS as
compared to the pre hospital system which failed in the
past is because the hospitals had no stake in it. Pre
hospital and Hospital two independent components of
Emergency Medical treatment-- should be integrated to
deliver appropriate treatment in a timely manner.
EMS can be organized in one of the following modes:
v Government
v Jurisdiction-Directed System
v Voluntary
v Private- business
v Public-Private partnership-Ahmedabad Model
complex system, hospital base
Based on the experiences of EMS Ahmedabad Dr.Joshi
highlighted 15 essential components for the success of
any EMS which are as follows:
v Manpower
v Training
v Communication
v Facilities
Critical Care Units
v women, children and rural poor continue to utilize PHCs
v Public safety agencies
v Consumer Participation
v Access to care
v Patients transfer
v Coordination of Patients' Record Keeping
v Public Information and Education
v Review and Evaluation Disaster Plan
v Mutual Aid
Report 24
Session 2 : Other Models of PPP: Selected
Experiences
Chairpersons: Mrs. Ganga Murthy, Economic Adviser,
MOHFW and Dr. P. P. Talwar, Chairman, MODE
Services Pvt. Ltd.
Rapporteurs: Dr. Pushpanjali Swain and Dr. Hemanta
Meitei, NIHFW
PPP - GTZ Experiences, Maharashtra
Presentation by Ms. Manjusha Doshi, Programme
Officer, GTZ, Pune
The objective is to enhance the quality and reach of
Government health services by harnessing resources
through partnerships. The approach here is to bring
together private and public partners and community
through technical support mechanisms. The strategy also
involves mapping and pooling of resources, exploring and
informing resources to Government partners for their
appropriate intervention.
Modus operandi
The process of forming a PPP is by participating in micro
planning, pooling of resources, liaison with the concerned
stakeholders, facilitation of the process and helping for
raising awareness and bringing conceptual clarity to the
working systems.
The results of PPP are:
u Continuing Medical Education” for Medical Officers
by private hospital
u Management training of PHC staff by NGO
u Training of NGO staff by PHC staff
u Partnership with International NGO, for the
maintenance of medical launch.
u Support for Nutrition intervention by SNDT College
of Home Science, Pune.
The Challenges faced:
Firstly, there is no clear-cut definition of PPP, secondly, it
is very difficult to retain the interest of the private partner
and thirdly, unattended commitments pose a threatening
situation in joint ventures. Fourthly, the process is time-
consuming and lastly community partnership and
ownership are a big challenge and the role of technical
supporters and facilitators is important for sustaining
interest and commitment.
Way Forward
C o n s i s t e n t a n d c o n t i nu i n g m o t iva t i o n a n d
communication is needed for a successful PPP. There is
also a need to sensitize the Government partner. The
community dynamics should be well understood and
efforts should be made to target promotion of
community ownership and participation. Close follow-
ups, feedback and feed forward with private partners and
complimentary partnerships are needed. There is also the
need for an apex body, which can execute the PPP
activities both at the State and Centre.
Industrial Adoption of Primary Health Care Centres in
Tamil Nadu: Is it a sustainable model of partnership?
Presentation by Dr. D.Varatharajan, Associate Professor,
Achutha Menon Centre for Health Sciences Studies,
Thiruvananthapuram, Kerala
In June 1998 when the Tamil Nadu Government decided
to involve the industrial sector as partners in enhancing
the public sector efficiency, the idea was to increase the
access to health care and thereby eliminate the rush for
facilities meant for referrals.
Methods of participation
u Model-1
Meeting the total PHC expenditure (salary, medicines,
purchase & maintenance of equipment, and civil works).
u Model-2
Meeting the expenditure on medicines, equipment and
civil works (salary by government)
u Model-3
Provide equipment, civil works and periodic maintenance
of the buildings.
Industrial response
† In 4 years, 34 industrial units have 'adopted' 70 (5%)
PHCs
† Model-3 was the most (82.2%) preferred option
The reasons for adoption were to develop better rapport
with the community. Improvement in PHC client load
would serve to promote various health services and serve
as an advertisement to draw more people to avail services.
More than the asset base created by the intervention, it has
helped to activate a major part of idle capacity.
Manifold benefits came up from this engagement, some
benefits accrued to the community were related to
improved quality of care and wider range of choice.
Some of the comments of the stakeholders are:-
“Industrial units even send their workers to give blood for rural
patients”
Community leaders
“It is a well-defined targeted investment and so, the benefits are
sharper and more than other interventions”
Government Bureaucrat
Report 25
“The intervention has reduced the transport cost and wage loss while
helping people to access wide-range of facilities. Earlier, they used to
spend two days to receive care from such facilities. Now, they need to
spend only half an hour to receive the same level of care”.
A PHC Medical Officer.
Benefits to the staff were in the form of better work
environment and job satisfaction had also gone up after
the intervention. “There was a time when medical officers spent
resources from their pocket to provide certain essential facilities to the
patients. At least, this situation had changed now”.
PHC Medical Officer
Tax exemptions, publicity, and community support were
some of the benefits to the industry. A group of
'adopters' even magnified their real support by 10 times to
draw public attention. Sustainability is always tagged as an
impediment in implementation of PPPs. While policy
makers, industrialists and medical officers felt that
industrial participation was a good thing to happen to the
PHC but they were not happy with its progress and pace.
Without a policy initiative as a complimentary measures by
the government this scheme may run into rough weather.
For example if the industrial unit creates a surgical theatre
and the Gover nment fails to provide a
surgeon/anaesthetist, the intervention would be rendered
meaningless.“While the industrial involvement is commendable
and is doing well so far, we, the staff, should show results so that the
industry gets interested in the policy in future and provide sustainable
support”.
PHC staff
Industrial support has made an impact on the functioning
of PHCs to some extent and improved the delivery and
sterilization services and the adoption of PHCs.
However, the support has not succeeded in altering the
composition of the clients approaching the PHCs. Only
services and it might require additional resources to draw
others towards the PHCs. Every industrial unit wants to
do something for the people. But, it requires a political
will to tap it for the overall benefit of the community.
Shaktikrupa Charitable Trust, Gujarat
Presentation by Shri. Jeetendra Patel, Secretary, Shaktikrupa
Charitable Trust, Gujarat
Community is an active partner in this partnership
between the state government and the Shaktikrupa
Charitable Trust (SKCT). Reaching the poorest of the
poor is the primary goal of this scheme The partnership,
which was initially formed for just two years, was later
extended to ten years. Experience says that to foster better
relations between the two sectors, both the sectors should
be willing to understand and appreciate each other. There
should be the principle of accountability, flexibility and
relaxation. The innovative nature of both the sectors
should be maintained. Various lessons can be learnt from
the development or innovative work during the entire
process. This includes conceptualizing and planning
followed by implementation, outputs and their reviews.
Keys to Success
†Self-development: Staff at all levels (from sweeper to
doctors) is encouraged to attend various seminars,
workshop-arranged programmes towards personal
development and capacity building. SKCT used the locally
available HR and developed their skills to improve the
delivery of the health services through motivational
capacity building and training.
The trust formed a team of medical professionals who
were committed and had stayed in rural areas.
†Spiritual Out look: SKCT emphasizes on certain values
& their consistence and tireless efforts to ensure that these
values & ethics percolate to all member of the
organization.
†Guidance and support: The staff receives guidance and
support at work by chief patrons of the trust (USA) and
all Government officers.
†Road map for future: SKCT, as a community Health
Centre, has struggled with the issue of how to deliver health
and medical services most effectively in an area of massive
need. This has led to the setting up of a three-tier rural
health care system, with Shree C.A. Patel Hospital as a
referral centre, and the training base.
Experiences of Janani in PPP
Presentation by Ms. Preeti Anand, Manager-Coordination,
Janani, New Delhi
Is there an opportunity for large scale supplementation of
the public sector? This was one of the main points
brought out through this presentation. Considering that
PPP is oxy-moronic in nature as it brings two
contradictory entities together : the private with a greater
emphasis on profits and the Government whose prime
responsibility is to ensure that health facility reaches to the
masses with profits as a secondary priority. Therefore the
relationship has to be facilitated by various means.
Emphasizing on the necessary approach required for an
effective PPP Ms. Anand brought out the point that a
vertical approach needs to be supplemented with a
horizontal approach. A vertical approach is not feasible-
for example family planning will have to be mixed with
other services as people are reluctant to invest in
preventive health care, considering the lack of financial
resources.
Management: A successful PPP requires a strong
indicator based management. The emphasis should not be
Report 26
on achieving an ideal mode but on how to improve the life
of a particular person in the area, as different areas have
different needs. An ideal or a uniform model for all areas
will come in the way of an effective planning. "Franchising
and bundling" strategies are some of the approaches
adopted by Janani. The franchising is done through rural
Titli Centres. Each centre has a man and woman to
provide health services. Currently Janani is working with
40,000 rural centres. Each rural centre pays a minor annual
fee, as a monitoring mechanism. Janani has established a
large network and delivers 21% of the family planning
services. A large network makes it possible to deliver to a
larger section of the population.
Infrastructure: Considering the limited infrastructure and
limited finances the need is to leverage the infrastructure
that is already there and not just on creating new
infrastructure. Creating new infrastructure initially will
divert all the limited finances away from the immediate
health requirements. The Ministry will have to take charge
for cost efficiency and programme implementation. The
economies of scale have to be looked after by the Ministry.
Working only through subsidies can be cost inefficient.
Other ways and means will have to be worked out to meet
the financial needs. The public sector at the end of the day
cannot deliver to all. Designing of a public private
partnership is important. The experiences of Janani in
Bihar go a long way in making this point clear.
HOSMAC India Private Limited
Presentation by Dr. Vikram Anand, General Manager-
Operations, HOSMAC India Pvt. Ltd., Gurgaon
The importance of PPPs in health care delivery facility
was highlighted. This can be done more successfully
through establishing a wide network of people.
HOSMAC's strength is its people. The right combination
of people and right combination of skills can go a long
way in making PPP more effective. The Australian
example in PPP was brought out. Australia has a
successful running PPP model. The various projects are
run by autonomous bodies. The biggest strength of these
projects is its people. Although autonomous in nature
these bodies are accountable to the management at the
end of the day. Thereby, greater autonomy does not
necessarily mean less accountability. On the other hand, it
helps the people to function and work with lesser hurdles.
At the end of the presentation the question of who is to
do what and for whom was pointed out. A simple model
of Human Development ensures that the right people are
at the right place. This is absolutely necessary as a simple
involvement of a large number of people is not enough.
What is more important is the right combination of the
necessary skills. It was also pointed out that the qualitative
aspect of health schemes should be looked after by the
Private Sector as the Public Sector has been unable to
deliver proper quality services so far. And HOSMAC's
experience has brought out the same point. Greater
autonomy, better quality is the need of the hour and an
effective PPP will help in this direction.
Ethical Issues in Public Private Partnership for Health
Care In Haryana
Presentation by Dr. M. M. Goyal, Professor of
Economics, Kurukshetra University, Haryana.
Justification for public-private partnership (PPP) in health
rests on the evidence that it brings efficiency, sufficiency
and equity in the health care system in Haryana. Public
Health services and Private sector services are twin sisters
and are complementary to each other, which justifies
collaboration. Implementation, monitoring and
evaluation of the well-identified objectives of Vikalp
requires an assessment and analysis of qualitative and
quantitative data. Developing a sound and honest system
is a tight ropewalk since expectations of high margin of
profit would primarily propel the private partners. The
marriage between public and private is possible by
accepting, understanding and analyzing ethical challenges
which are justified as an important component of PPP in
the adage “if wealth is lost, nothing is lost, if health is lost
something is lost, if character is lost everything is lost.”
To prove PPP as an innovative approach for promotion of
health culture we need to conduct SWOT analysis of the
scheme. It needs to be pointed out that the services of the
PPPs would be popular only if they satisfy the essential
needs of the public and is utilitarian. Publicity alone
cannot be a substitute for the basic requirement of Need,
Affordability and Worth (NAW) of the services by the
PPP. To adopt and accept the normative approach to
HRD in PPP it is essential to understand SIMPLE model
of HRD (developed by the author elsewhere) consisting
of six human development activities such as Spiritual
Quotient (SQ) development, Intuition development,
Mental level development, Love yourself attitude
development and Emotional quotient (EQ) development.
The synergy of these six aspects of HRD is essential
requirement of the desirable human resources for the PPP
to emerge and realize its full potential. Above all, we need
confidence building, mutual trust, faith, commitment and
political will. 'Not me but you' selflessness to replace
selfishness of the so-called rational behavior of
stakeholders. Training in spirituality is the mantra of true
collaboration of Public and Private sectors in health care,
which is a service to be provided by a motivated
manpower in PPPs.
PPP Initiatives of Rogi Kalyan Samitis in MP
Presentation by Prof. Alok Ranjan Chaurasia, Professor,
Academy of Administration, Bhopal
Report 27
Rogi Kalyan Samiti, as an organization, had its beginning
in Indore, MP, and took up a radical approach of making a
change in the functioning of the health care facility
through participatory approach. The initial stock was to
make the hospital/health centers clean. After the success
of the Samiti, the Government adopted the RKS scheme
for all the hospitals. The work areas of the Samiti span the
entire spectrum of services including the coverage,
feasibility of the services, utilization, accessibility and
evaluation of RKS.
Three models are experimented at different levels such as
primary, secondary and tertiary. The importance of the
RKS in all these levels was based on the fundamental
principles of inability of the Government to undertake
service delivery, scarcity of resources for health care
service by government, lack of information of health
seeking behavior of the community, and non existence of
regulatory framework.
With the assistance of RKS, hospitals raised funds,
ensured a dual management system for raising and
utilization of funds. The results of the initiatives
undertaken by RKS have resulted in concentration of
certain services in selected CHCs and no proper channel
of utilizing funds. In order for a successful PPP, it also
emphasised the role of PRIs and mostly the outreach
services. It was so arranged that the Tertiary sector should
function autonomously while the secondary sector should
use funds for clinical services.
Initiatives of National Institute of Medical Statistics
Presentation by Dr. H. K. Chaturvedi, Assistant Director,
National Institute of Medical Statistics, New Delhi.
The website www.prod-india.com is part of the data base
[HS-PROD] which has complied studies on PPP. In the
area of emergency obstetric care the work undertaken by
Dr. Nandini Roy in the State of Tamil Nadu was cited as an
example of successful partnership effort. NGOs were
required to maintain vehicles for the below poverty
population whereby about 30-40 emergency cases were
transferred to the hospital, and emergency service was
made available within 50 km. of the highway. The
advantage of the programme was cost effectiveness and it
saved lives. These PPP experiments also indicate that
these initiatives are not without startup problems and
these are not self sustaining since the loss is consistently
incurred by NGOs.
Discussion :
Impact of the Janani programme in Bihar has been
significant since neo-natal deaths have been reduced
drastically. However, if one looks at the indicators of birth
rate and IMR, then impact is negligible. Janani through
their scheme provides condoms and oral pills to newly
married couples and to any one who desires to have it. No
such modalities are followed for distribution of
contraceptives. Reacting to question about non-
functioning of some PPP's, it was suggested to follow
Karnataka model which worked efficiently and could be
shared with NIHFW as a viable experiment.
Sustainability aspects of various PPP initiatives were also
discussed. It was felt that public sector could not deliver
health services to all given the constraints of resources,
manpower and infrastructure. Formation of a working
group was required to bring in hope and confidence in
taking the movement forward. Various successful
experiments on PPP are defined by their designing,
coordination and the funding mechanisms.
Recommendation based on the review of the such models
should be submitted to the Ministry for mounting the
programme on a large scale.
Chairperson's Remark
At the end of the session, the Chairperson, Prof. P. P.
Talwar, said that it was a rewarding experience to learn
about variety of PPP models shared by the presenters at
the session. Here we should identify good models to make
a quick evaluation of their feasibility in introducing them
elsewhere in the country. This was the best way to multiply
and strengthen the PPPs. Mrs. Ganga Murthy, the other
Chairperson of the session , summarized that a stage had
come when public sector could not deliver health services
to all and therefore PPPs in health sector was inevitable.
However, design of partnership was critical which
depended on available resources at the local level for
which mapping of health facilities was required. It was
important to study couple of experiments including their
design, funding, management inputs, co-ordination etc. in
order to understand factors that facilitate their
success/failures.
Session 3: Brain Storming Session
Chairperson: Dr. M. R. Surwada, Head, Public Health,
EPOS, New Delhi
During this session, the participants were divided into
three groups and each group was given a topic to work
upon and sug g est practical and achievable
solutions/recommendations to take forward the PPP
process in different service areas. The objective was to
discuss the following topics:
Delivery of health services under National Health
Programmes (NHP);
Delivery of curative and diagnostic services at various
levels;
Delivery of health services in un-reached areas.
Each group was asked to appoint/nominate a group
coordinator to manage group discussions and within the
group brainstorm issues related to service areas and
Report 28
suggest the appropriate model for PPP in which there was shared rather than the tendency of the public partner address PPP problems. NGOs obtaining grants from
potential for PPP. Subsequently suggestions and ideas should be dumping its burden on the private partner. agencies other than the government like UNDP, WHO
were sought on following topics: Equal status to both parties in terms of responsibility, risk and other international agencies should be open to
management and outcome should be a feature of the scrutiny and discussion.
Policy and strategic implications on:
PPPs programme. This would be possible if an
Organizational, financial and structural implications Government should ensure timely release of funds to
u independent PPP cell, at the Central, State and local level
and suggestions private partners. Keeping in mind the private provider's
with representatives of both the partners, is established
concern of profit maximization, the public sector should
Implications for legal and regulatory mechanisms for monitoring and regulation of the PPP initiatives.
u be clear about its priorities at the outset and affordability
Recommend approaches for monitoring and This partnership, characterized as it is by a human touch, of the services to be provided by the private sector
u
evaluation should not be confused with privatisation. The chosen hospitals, nursing homes and MCH Centres. Government
model should be self-sustaining, and the future long-term could make attractive offers like offering PHCs for
Solutions/recommendations for capacity building/
u anticipated outcome should be kept in mind. Legal management and giving free land for setting up hospitals,
development. problems and punishments like stoppage of grants, tax waivers for five years, etc.
Roadmap for future highlighting: withdrawal of recognition for the erring NGOs should
be discussed. There should be a legal framework to
u What needs to be done on a priority basis
u Type of inputs required
u Role of different stakeholders like State
Government/PPP units, NIHFW, National Health
Resource Centre, Donor Agencies, Private sector, Civil
Society/NGO's
Areas where Public Private Partnership could work:
The brainstorming session led to the consensus that PPPs
could work effectively in providing preventive, promotive
and curative services. More than 30- 40 per cent of public
health care infrastructure is unutilized or under-utilized.
Private sector should take over and fill in the deficiency.
Private sectors could handle well the vaccination and
family planning services. In PHCs where medical officers
and staff are not always available, the private sectors or
NGOs can efficiently run it. Joint efforts of both the
partners could be more effective in BCC and IEC,
especially in spreading awareness and removing stigma
regarding AIDS, TB, leprosy, malaria etc. It will also
improve the logistics and drug supply at primary health
care level. At the secondary care level NGOs can also
complement the work of the government in the provision
of free diagnostic and curative services. Specialists can be
engaged on contract basis. Outsourcing of diagnostic
services like X-Rays, CT-Scan, lab tests, etc. can prove to
be an efficient management, maintenance and up
gradation of the technologies in cooperation with
speciality and other hospitals with technical expertise. The
private sector already shares the largest chunk of the
tertiary care level. Hence effective regulatory mechanisms
for the PPPs would be fruitful both for public and private
partners and for the people at large.
Relationships and Expectations:
Participants agreed that mutual trust, transparency in
MOUs and accountability on both sides were the premise
on which partnership and relationship would be mounted
to make PPP functional. The goals would have to be
Report 29
 30 November, 2005
Presentation by Groups
PPPs for Delivery of Health Services Under National
Health Programmes
Chairpersons: Dr. J.P. Steinmann, Programme Director
Health, GTZ and Dr. M.R. Surwade, Head, Public
Health EPOS
Group I
The group presented some of the important mechanisms
that are required for PPP initiatives. Highlighting the
importance of autonomy, the group pointed out the need
to have autonomous State and district level PPP cells. The
cell could have members both from the public and the
private sectors. Thus autonomy and a right mix of
representation should be the most important aspect of a
successful PPP. In addition, these cells should take up the
orientation and capacity building of the cell members
from time to time. As the nodal agency of the PPP, the cell
would work in tandem with the health and family welfare
societies. As the mainframe of the PPP initiative, the
viability of cells would have to be beefed up with sound
financial allocations. Quick action must be taken against
defaulters and partners who fail to comply with the cell's
operative procedures and laid down norms and standards.
The cell should adopt an integrated approach of focusing
on one component, one area, and one partner and avoid
duplication. This will go a long way in avoiding excess
expenditure resulting from duplication of services and
taking too many partners on board. Some of the
justifications for a successful PPP initiatives are obvious
since the synergy of coming together of the public and the
private partners will carry forward to optimal resource
utilization and reduce wastage. This synergy will bring
about cost effectiveness, improve, efficiency and build
work ethics. At the end of the day, both partners will be
answerable to each other and accountable to the people of
the region.
The importance of good management, teamwork and
leadership cannot be over-emphasised in a collaborative
effort. PPPs require coordination at the decision-making,
implementation levels and monitoring of services which
can be made possible by effective teamwork. Partnering
with community organizations, like Panchayats in rural
areas and Resident Welfare Associations in urban areas,
will reinforce the dictum, 'essence of PPP is by the people,
for the people and of the people'. All this leads to the
conclusive evidence that PPP has to be a decentralised
effort from the Center to the States, to the districts and
finally to the level of panchayats to ensure that services are
rendered for the benefit of the local people. Legal and
regulatory mechanisms, like MOU and TOR, should be in
Report 30
place in case of disputes between the partners to avoid logical first step. These areas include urban slums, tribal which the partnership can be carried out. The
conflict. Conflict Resolution mechanism should be put in population, hilly areas, areas where there are only private involvement of the community at the micro level will be
place to avoid complications between the partners. health services, areas where there are only public health an added advantage.
services and areas which neither have the advantage of
Discussion: The public sector should shed its traditional Discussion
private nor public health services. This geographical
unilateral bias for a multi-sector outlook since the Operating at different levels means working at different
inequity in the delivery of health services along with poor
emphasis has to be on convergence of resources and ideas levels. A situational analysis of a hilly State like Uttaranchal
connectivity speaks volume of the task that lies ahead for
in equal measure. Planning is a mandatory requirement for is required before carrying out any operation. Health
PPPs in health. Traditionally, private sector has always
establishing any kind of unit. As a prerequisite, an Insurance cannot be taken as a panacea where there is the
kept away from areas where there is less or no scope for
assessment about its functions and for whom the unit will added advantage of health facilities. A listing of the
profit. Inaccessible areas have different needs and
perform needs to be undertaken? These functions have to existing infrastructure is the logical first step as people
requirements. Therefore the "one size fits all" approach
be considered before taking the next step. cannot pay premium for sub-standard care. Moreover
cannot work in the field of health. It is in these areas that
Group 2 the public sector has shown a greater presence than the there is no point harping about private doctors not going
private sector. But even in these areas the public sector to rural areas. What is required is an up-gradation of skills
PPPs in Delivery of Curative and Diagnostic services at
various levels although present has not been able to provide quality of people at the rural level. The emphasis should be on
service. It has often been unable to meet the demands in self-sufficiency and on how we can build capacities for
Responsibility, performance and accountability are the these areas. There is also lack of diagnostic services. It is people in the inaccessible areas. A holistic approach
building block of PPPs. The emphasis should be on a here that PPPs can bring about the right mixture of quality towards health is required to provide for the health of all.
meaningful partnership, especially with regard to un- and quantity and fill-up on each other's weaknesses. An improvement in the health sector can be brought
reached areas. A partnership can be meaningful only if it is about through a multi-sector approach. Poverty
able to bring more and more people under its health Since a majority of the hospitals in the rural and other un- alleviation, education and health must all go hand in hand.
scheme. Although the focus has to be on the primary, reached areas are run by state governments, the success of The Government because of its presence in rural and
secondary and the tertiary level, yet the secondary level, the initiative hinges on their cooperation. The health other inaccessible areas needs to take the responsibility for
where accessibility is the most important issue. Without providers have to be defined more clearly. Contracting-in, PPPs. The success of the experiment hinges on their
reaching the un-reached areas where a large number of the contracting-out, social franchising are some ways through cooperation.
population resides, health reforms will not be able to take-
off in a big way. Accessibility, affordability and availability
are very important since no health scheme will make
practical sense if people cannot afford the schemes and
cannot get medical help when required most of the time.
The possible partners in PPPs may include the public and
the private sector, NGO's and Panchayati Raj Institutions.
Some of the possible administrative mechanisms for
PPPs may be the establishment of a registered body,
networking, leasing, and decentralization. Planning and
monitoring the role of each partner has to be defined
separately. This would help in bringing about more
responsibility.
However, the group brought out the importance of some
aspects beyond PPP such as political and administrative
commitment and will and an equal sharing of resources.
Discussion: There is a need for information and data. In
other words mapping of the resources should be done in
advance. Quality must not be overlooked at any cost. And
finally there is a need for equity- an equitable health
system. Moreover there is a need to define “public”. Is it
only government or community and PRIs as well? There
has to be greater clarity in this regard.
Group 3
PPPs for Delivery of Health Service in Un-reached
areas
There is a lot that ails the health system today in order to
make things better, a listing of the un-reached areas is the
Report 31

Emergent Issues and Recommendations
New concepts of development highlight the need to
catalyze private investments in developing countries and
illustrate that corporate growth strategies can address
development goals and improve the bottom line.
Strategies to promote effective PPPs must consider how
governments can further reduce bureaucracy, counter
corruption, and create more stable business environments
to stimulate growth and accountability. Equally important
is to determine how the private sector can be encouraged
to make genuine commitments to sustainable
development while adhering to high standards of
governance and accountability and transparency. There is
a need for public private partnership as more than 70 per
cent of patients avail services from the private sector
hospitals which are more likely to detect early warning
signs of disease outbreak since these are the first contact
points for poor patients as well. Lack of adequate facilities,
chronic staff shortage and incessant delays in provision of
treatment and health care in the public sector is the raison
d'être for the private sector's participation in the
partnership.
Some of the common problems in PPPs are:
uAt times inadequate Government-NGO interface
breeds discontent and creates skepticism about the
motives of the private sector. Often the nodal officer does
not have a copy of the scheme and is not clear about the
working guidelines which proves a hindrance for the
private partners and NGOs.
uThere should be sharing of the risks and liabilities
between the public and private partners. For example
there might be reluctance on the part of the Government
to hand over to NGOs movable property like ambulances
as it might lead to litigation later. In West Bengal this
contentious issue was solved by allowing the NGO to
operate the ambulance though it was owned and
registered in the name of the Government.
uThere is lack of proper classification in PPPs especially
with regard to those Below Poverty Line (BPL) and Above
Poverty Line (APL). Cross subsidizing would prevent BPL
patients from being excluded from receiving health care.
uThere is need for social auditing and a system of
monitoring. At present there is no mechanism to monitor
quality. The poor have high physical and social access to
the non qualified providers. Any successful course of
action will have to address the realities of the political
economy of rural villages.
uThere is no clear cut program for PPP initiatives which
would address the existing social inequality. The area of
Report 32
operation for public and private initiative is undefined.
There is a clear-cut division between curative and
preventive care with private sector emphasizing profit
making and super specialty curative care while the public
sector on preventive and promotive care.
Challenges relating to fund flow, logistic management,
u form the basis of accreditation as well as of benchmarks
mutual trust, transparency, licensing and sustainability of
PPP initiatives, if managed with dexterity, can ensure an
easy run for the PPPs. Inadequate and unqualified
manpower are the perennial problems that characterize
the public sector with lack of motivation proving to be the
'proverbial death knell'.
u Corruption is ubiquitous, both in public and private
sector. Absence of regulating principle makes it more
difficult to handle.
Recommendations:
It emerged from the deliberations that PPPs could
u
improve accessibility and quality of health services and
result in relaxation of bureaucratic procedures and red
tape. PPPs are seen as 'win-win' arrangements in which
diverse actors with varied motivations and philosophies
work together, albeit with different motivations, and are
able to contribute to health of the people and
development of the country.
uIt was proposed that the role of the GOI would be to
identify areas in NHP, diagnostic and curative services
where partnership was possible by suggesting area specific
models. The basic premise should be patient-centric
approach with people at the grassroot level taking part in
the decision making as partners.
u GOI may develop working guidelines based on
successful experiences of different States. MOUs/
contract agreements, control mechanisms, monitoring
and evaluation, feed back system etc should be designed
to oversee the implementation of PPPs with regulation
mechanisms in place.
uMonitoring & Evaluation: PPP cells can be the nodal
agency for monitoring and evaluation. Random quality
checks by state level officials and qualitative and
quantitative benchmarks for performance should be
developed. Self-monitoring and peer-review networks of
professionals can also be one of the innovative
monitoring and evaluation strategies. Management
Information System (MIS) should become the mandatory
management tool for assessing the trends and making
assessments about the efficacy of the PPP system.
u The elements of profit making of the private partners
should be kept taken into account. Government should
involve at least one 'for-profit' and one 'not-for-profit'
actor. Feasibility study (SWOT analysis) should be done
before embarking on any PPP initiatives.
uGuidelines for implementing any PPP arrangements by
hospital societies like RKS may be developed. Quality
guidelines should be framed with assistance from
professional organizations, which already have experience
in preparing quality assurance tools. These guidelines can
and performance based indicators. There should be
proper guidelines for selection of NGOs based on
recommendations from donors, credibility based on
documentary evidence and certification by opinion
leaders of the area, field appraisal procedures, etc.
uIn the case of a PPP being unable to break even, there
should be an exit policy for the private sector.
u PPP cells at Central and State level should be made
functional at the earliest to undertake to site visits (in
other States) where successful PPP models are under
implementation.
u A cell for promoting PPPs can be created at NIHFW
with financial support from MOHFW and other donor
agencies. Capacity building and sensitization workshop
for State level officials on PPPs may be jointly taken up by
NIHFW.
uMapping: Mapping of dysfunctional Primary Health
Centers/ Community Health Centers and private sector
health facilities would provide an updated account for
partnership feasibility. Tracking number of health
practitioners available in the state would help in making an
assessment of specialties and availability for their
involvement in the initiatives.
uFinance: Cost and economic considerations are
imperative in undertaking partnership schemes for which
the government may work out the operational cost per
unit service. Allocation of funds in the state health budget
for innovative schemes would ensure a dedicated fund for
Report 33
the PPPs. User-fee should be utilized locally. Price may be
fixed on the basis of (say 50-70%) operating cost.
Government should facilitate easy fund flowing
mechanisms. Tenders should be invited only from
professional agencies for greater efficiency and revenues
to contractors should be increased.
uTechnology: There should be flexibility and openness in
approach in the use of modern technology.
uAdvocacy: Efforts involving national leaders, well
acclaimed professionals in the field and other luminaries
would provide consensus and an environment to generate
demand for PPPs. Politicians, policy makers,
administrators at State and district level may be sensitized
about mechanisms and benefits of PPPs. Campaign
approach is required, especially in bigger states like UP, to
reach the masses. Education should be given through
entertainment and use of folk media for reaching out to
people in the. Four Cs of partnership are required namely:
Communication, Consultation, Coordination
andCollaboration.
u There is a need for understanding community
dynamics. Ownership of community should be roped in
for sustainability of PPPs. An understanding of the
role of panchayats and Community Based
Organisations facilitate in successful PPP
arrangements.
u Promote industrial participation through bodies like
CII, FICCI which can activate idle capacity in the
private sector. This can be done by identifying and
mapping poorly secured health centers and nearby
industries which can be given the offer of running these
centers under the PPP scheme.
u Inducting Cooperatives (diary cooperatives, farmers'
cooperatives) and field-based NGOs to improve health
services coverage.
u Provision of subsidized and free health care for the
poor and equal mandate for preventive measures
should be developed. This should be reiterated by
strong policy backup.
 Conclusion: Promises to Keep
There is growing confidence in the power and attributes
of Public-Private Partnerships to narrow the
development gap and usher in such practices to meet the
needs of the people, especially poor communities. PPP is
an initiative to implement the health sector reforms in a
manner in which private sector complements and
supplements the inadequacies of the public health sector.
The Government is also of the view that PPP is an
indispensable strategy, given the performance of the
health sector in the last decade under the aegis of the
health sector reforms. The consensus at the workshop
was to reiterate that profit motive alone should not guide
the interest of the private sector and lead to health
inequities and dehumanizing treatment of the poor
people. To redress this lacunae, partnership guidelines
should be in consonance with the profit motive of the
private partners as well as free treatment need of the poor.
In conclusion, PPP has to be understood as a means to an
end. The main purpose is to deliver quality health service
to one and all. The normative needs of professionals
should overlap as much as possible with the felt needs of
the people, especially for those who have less or no access
to health services. Therefore, one has to look beyond
PPPs in the long run with the ultimate aim of providing
better health services to all. This would also mean
democratizing the process of rendering services, since the
target population will be no longer recipients merely, but
participants in the process of service creation, functioning
and access. Besides, active people participation would help
to overcome and minimize red-tape, an issue which the
private sector holds against the Government.
Report 34
This point can be linked to Dr. Steinmann's (GTZ) idea
that there was need for change in the current status of
PPPs in the minds of both, the public and the private
sectors. We view PPP as a 'substantial partnership' in
which the Government gives a contract and the private
party brings 'substance' in the form of funds. In order to
evolve better, it is necessary to break through such
formulations. It could be a 'structural partnership' where
the parties involved "begin at the beginning". Decision-
making and resource allocation will then follow according
to the need and feasibility of the task at hand and the
suitability of either sector to handle particular aspects of
the project. The cryptic remark that 'working together
works', made by Mr. Krishnaswamy of SIFPSA, in a way
sums up the orientation and the context in which all
initiatives have to be made for the PPPs. Dr. Shubnum
Singh of Max Healthcare pointed out that at present
quality monitoring and accreditation is an individualistic
process, since there were no common/collective
standards for judging quality and quality control. There is a
need for an autonomous contracting and accreditation
body for setting standards that are not mere imitations of
'Western standards', but have a meaning in our lives
(established standards must not be removed from
local/regional/national practice). This idea can be linked
with the recommendation that stated "the Government
of India should implement area specific models of PPP"
which implies greater decentralisation of services keeping
in mind the federal nature of our country.
Consolidation & Way Forward
Chairperson: Prof. N. K. Sethi
The final session led to consolidation and way forward. This
session was chaired by Prof. N. K. Sethi. The following
major issues which emerged out of deliberations during the
workshop were synthesised:
t Based on evidence it is necessary to identify key areas
for PPPs in NHPs, diagnostic and curative services
etc.
Efforts should be made to design partnership
t
arrangements for long-term sustainability. Working
guidelines for structured partnership, based on
successful experiences of States, MOUs, /contract
agreements, control mechanisms, monitoring and
evaluation, feed back systems etc. which have proved
workable should be documented and disseminated
among stakeholders.
t The element of profit making of the private partners
should be taken into account while developing any
PPP model. Providing output based incentives to
private sector should be based on the concept of
sharing risks and benefits.
t Feasibility study (SWOT analysis) should be
undertaken through professional bodies before
embarking on any PPP initiative.
t It is important to understand community dynamics
in implementing any health programme. Therefore,
ownership of community should be roped in for
sustainability of any PPP arrangement. Panchayati
Raj Institutions and Community Based
Organisations should be involved in monitoring and
evaluation of PPP initiatives.
t State Governments should promote industrial
participation through bodies like Confederation of
Indian Industries, FICCI and other such
organisations can activate unused/underused
capacity of public health facilities.
t FICCI and other such organisations can activate
unused/underused capacity of public health
facilities.
t Appropriate scheme(s) could be designed to rope in
co-operative societies and NGOs to improve health
services coverage through PPPs.
t NGOs to improve health services coverage through
PPPs.
t Bureaucratic procedures are often stringent and
affect the pace of implementation of PPPs in health.
Therefore, it is necessary to simplify administrative
and bureaucratic procedures.
Report 35
t Costs and economic considerations need to be
considered while designing any PPP model.
Operational cost per unit service at different levels of
public health facilities may be worked out to decide
price (user charges) per unit of service.
u S t a t e G ove r n m e n t s m a y e n c o u r a g e P P P
arrangements by hospital societies like Rogi Kalyan
Samitis (RKS), Medical Relief Societies (MRS) etc.
Funds collected through user charges may be utilized
to improve quality of services through PPP
initiatives.
Action Points
1. Capacity building and sensitization workshops on PPPs
for State level officials may be taken up jointly by
MOHFW and NIHFW. Politicians and policy makers may
also be sensitized about mechanisms and benefits of
PPPs in Health and Family Welfare.
2. PPP units at Central and State level should be made
functional at the earliest. Personnel managing PPP units
may visit and study the sites where successful PPP models
are under implementation. Seed support may be provided
by the Central Government and technical support may be
extended by development partners.
3. A cell for promoting PPPs in the country can be created
at NIHFW with financial support from MOHFW and
other donor agencies. It was also suggested that PPP
consultants under the proposed National Health System
Resource Centre could function from NIHFW.
4. There is a need to develop a comprehensive policy
framework on PPPs by States. Technical guidance and
support from Central Government, Donor Agencies and
other technical bodies may be provided.
5 PPP schemes under NHPs may be integrated for better
involvement of more NGOs/private sector.
6. There is need to design appropriate area specific flexible
mechanisms for accreditation of private health sector for
their involvement in PPPs. Existing American and
European standards may not be meaningful to our
programme.
7.GOI may come out with broad policy guidelines for
leasing out unused/underused infrastructure to private
sector/NGOs under PPP initiatives. Private sector needs
handholding by the Government.
8. Dispute redress mechanism may be evolved under PPP
initiatives for resolving problems at the earliest.
9.Decision on following issues was also taken:
N To send minutes and action points to all participants for
their feedback and further inputs.
n Participants would inform NIHFW how their
organizations could contribute to future activities related
to PPPs within a month.
n Participants would inform NIHFW about other
organizations which are actively involved in PPPs, so that
further networking could be made with those
organisations.
n Participants would send the details of their
presentation, comprising of process followed,
TOR/MOU, financial details, system of monitoring,
assessment done, factors that affected success/failures
and suggestions for future etc. ,within a period of one
month.
n NIHFW would share the details of presentations and
related documents received from States as well as other
organizations with National Institute of Medical Statistics
for further strengthening its network and dissemination
through website.
n To constitute a core group consisting of representatives
from major States and organizations, which are facilitating
implementation of PPP initiatives. The core group, with
the help of experts, would further consolidate group work
recommendations and carry forward the proposed
actions. Organizations such as EPOS, Max Healthcare,
SIFPSA, GTZ volunteered to be members of the core
group.
Report 36
Last Word
The Model adopted in Kannur in Kerala is a good example List of Participants
of a successful PPP model where the reduction in the total
number of T.B. cases has shown a steady decline of 10 per
cent to 20 per cent under the Scheme. In such a Participants from Outside Delhi
programme the benefits of the scheme have been serviced
directly to the clients. A comprehensive PPP where Dr. Sanjay Bhardwaj Dr S. K. Mishra, IAS
success is measured on the scale of competitive services Consultant (HRM) Additional Scretary, (T)
made available to people who otherwise would have had Sector Investment Programme Office Department of Health and Family Welfare
no access to such services would be the hallmark of such Office of Director General of Health Services Haryana Government of Orissa, Bhubneshwar, Orissa.
Sector-6, Panchkula. Ph: 0993760315 (M), 0674-2322405 (O)
initiative. It has been suggested that the role of public
sector and of the NGOs (other than private hospitals) dr_sanjay29@yahoo.com, Ph: 098152-28337
Dr. Gian Chand
should be clearly defined to help in the assumption of Dr. Raminder Singh Principal, State Institute of Health & Family Welfare
responsibility by each in the provision of technical Deputy Director (Nutrition)/Nodal Parimahal, Shimla- 171009
guidance and expertise by the Government doctors Officer PIP, Office of Director General Health Services parimahalshimla@yahoo.com, Ph: 09418100015
whenever considered feasible, and in the efficacy of Haryana, Sector-6, Panchkula 0177-2620226(O), 0177-5533566(R)
NGOs in the delivery of services in areas of their drramider@rediffmail.com, Ph: 09417014252
involvement. The role and responsibility of private Dr. K. Pattabhiramaiah
Dr. S. K. Naval Joint Director (USP)
hospitals should also be clearly defined. A brief
Civil Surgeon, Office of Civil Surgeon HM&FW Department
mechanism of monitoring and evaluation at regular
Hissar, Haryana. DM& HS Campus, Sultan Bazar, Hyderabad 500095
intervals should be established at the Centre/State levels Ph: 0416488831 Pattabhidoctor@yahoo.com, Ph: 24730206,09849902225 (M)
to provide a feed-back of the actual progress in the
delivery of services to the public and their active Dr. Vikas K. Desai Dr. Akash Rajpal
involvement in the planning and delivery of health Additional Director (FW) Manager Medical Services
services. The examples drawn from the experiment in Health, Medical Services & Medical Education (Health) Dr. L H Hiranandani Hospital
inter-sectoral cooperation for a common purpose should Gandhi Nagar, Gujarat -382 010. Akash.rajpat@hiranandanihospital.org
be widely publicized for the success of PPPs in the psmvikas@hotmail.com, Ph: 09825117259 Hillside Avenue, Hiranandani Gardens Powai, Mumbai 400076
country. Akash@rajpal.net, Ph: 09821152290 (M), 09820570161(M)
Dr. Ajesh Desai
25763300 (O)
Consultant (Maternal Health), RCH-II
It is desirable to forge and establish trust between the
Directorate of Health, Medical Services & Medical Dr. D. Varatharajan
public sector and the private sector, NGOs and hospitals
Education (Health) Assoc. Professor, (Health Economics & Policy)
in the organization and delivery of services. The private Gandhi Nagar, Gujarat -382 010. Achutha Menon Centre for Health Sciences Studies
hospitals have reportedly been getting subsidies on land, ajeshdesai@hotmail.com, Ph: 09825117259 Sree Chitra Tirunal Institute of Medical Sciences
water, electricty and concession in import duty on Thiruvananthapuram- 695011
diagnostic equipment and they claim through Dr. Haren Joshi
drrajan2001@yahoo.com, drrajan@sctimst.ac.in
advertisement that the poor patients would be treated at Prashasak
Ph: 09447148716 (M), 0471- 2524241 (O)
concessional rates. Actual delivery of services especially Samlaji, Dist. Sabarkantha, Gujarat.
to the urban poor and people living below poverty line and haren.joshi@gmail.com, Ph: 09825387293, 079-26860031 Dr. H. Sudarshan
those in the slums, should be monitored on a regular basis. Hon. Secretary, Karuna Trust
Shri Jeetendra Patel
It is desirable, as much as it is necessary, that a strong and Headquarters: B.R. Hills, Yelandur Taluk
Trust Secretary, Shaktikrupa Charitable Trust
Charamarajanagar District, Karnataka- 571441
efficient mechanism for monitoring & evaluation by an Mota Foflia, Taluka Sinor
Ktrust@vsnl.net, vgkk@vsnl.com
outside agency is set up at various levels of implementation Dist. Baroda, Gujarat.
Ph: 08226-244018, 244025
of the health programmes under the aegis of PPPs. cap@satyam.net.in, Ph: 098795 12041, 02666-275281
275073, 0265-2429256. Dr. S. Krishnaswamy
General Manager, Private Sector
Dr. B.K. Bhargav
SIFPSA, Om Kailash Tower, 19-A Vidhan Sabha Marg
Director (FW)
Lucknow, Uttar Pradesh 226001
Directorate of Medical and Health Services
skswamy123@rediffmail.com, skswamy123@hotmail.com
Swasthya Bhawan, Tilak Marg, C-Scheme Jaipur, Rajasthan.
Ph: 09415027460 (M), 91-522-2236211(O), 2308089- 8918(R)
Ph: 0141-2222422, 09414269602
Prof. M. M. Goel
Dr. Naresh Kumar
Department of Economics
O.S.D. (FW),
Kurukshetra University, Haryana.
Directorate of Medical and Health Services, Swasthya
mmgoel2001@yahoo.co.in, 01744-224178®
Bhawan, Tilak Marg, C-Scheme Jaipur, Rajasthan.
Ph: 0141-2221651®, 09814719475
Shri A.Krishnamurthy Mr. Vivek Singhal Participants from Delhi
Statistical Officer Treasuer,India Dev. Coalition of America Dr. Shuvi Sharma
Directorate of Family Welfare 2021 Midwest Road, Suite 200 Consultant, Social Marketing
Government of Tamil Nadu Oak Brook, IL 60523 Dr. Deepak Bhandari
Chairman & MD Futures Group, 1-D-II, Park Wood Estate
Annasalai, Chennai 9. v.singhal@idc-america.org, 630-705-3080
EPOS Health Consultants (India) P.Ltd. Rao Tula Ram Marg, New Delhi 110 022
Ph: 09444333307 (M), 044-22242407®
Dr. Dhanavanti R. Ghandge A-69, Hauz Khas, New Delhi 16 shuvisharma@futuregroup.com ,
Shri. P. Muniappan Medical Officer dbhandari@epos.in, Ph: 011-26963946, 011-26963579 Ph: 9811123079 (M), 011- 26712165/ 71/ 75
Demographer New Mumbai Municipal Corporation
Shri Hari Menon Prof. Peter Berman
Directorate of Family Welfare Mumbai.
Manager PPP Management Lead Economist, HNP
Government of Tamil Nadu
Dr. Alok Ranjan Chaurasia EPOS Health Consultants (India) P.Ltd. The World Bank, 70, Lodhi Estate, New Delhi -3
Annasalai, Chennai - 9
Professor & CEO A-69, Hauz Khas, New Delhi 16 pberman@worldbank.org, Ph: 011- 24617241
muniappandemo@yahoo.co.in, Ph:09444289122(M)
Population Research Centre
044- 22329511(R) hmenon@epos.in, eposHQ@epos.in, Ph: 09891195829 Dr. Rajeev Ahuja
RCVP Noronha Academy of Admn.
Shri Ayanabh Deb Gupta Health Finance Specialist
Dr. C. P. Arya Bhopal, MP- 462 016
Addl. Director, Directorate of Medical Health & Asst. General Manager The World Bank, 70, Lodhi Estate, New Delhi -3
Dr. (Mrs.) Vikas Kishor Desai EPOS Health Consultants (India) P.Ltd. rahuja@worldbank.org, Ph: 09818472833
Family Welfare, Uttaranchal, Dehradun, Uttaranchal
Additional Director (F.W.)
Ph: 09412364678 (M) A-69, Hauz Khas, New Delhi 16 Dr. Ambujam Nair Kapoor
Commissionerate of Health, Medical Services
ayanabh@epos.in, Ph: 011- 26963946(O), 011- 26963579 DDG, Indian Council of Medical Research
Ms. Manjusha Doshi & Medical Education, Government of Gujarat
Programme officer 2nd Floor, Block No.5, Dr. Jivaraj Mehta Bhavan, Dr. M.R.Survwade Ansari Nagar, New Delhi.
Indo German Health Programme Gandhinagar- 382 010 Head-Public Health ambujam@icmr.org.in, Ph:011- 26588296 (O)
New White House, 38, Suyojana adddirfw@gujarat.gov.in, psmvikas@hotmail.com EPOS Health Consultants (India) P.Ltd. Dr. R.N.Gupta
Co-operative Housing Society Ph: 079-23253311 A-69, Hauz Khas, New Delhi 16 Ex. Emeritus Scientist
Samta Chowk, Off North Main Road drsurwade@epos.in, Ph: 01126963946®, 09891268827(M) Indian Council of Medical Research
Dr. L.P. Bhojwani,
Koregaon Park, Pune- 411 001 Dr. Shubnum Singh Ansari Nagar, New Delhi
Dy. State TB Officr
Mdoshi.ighp@gtzindia.com,doshi.majusha@rediffmail.com Advisor-Max Healthcare, guptarn@hotmail.com,
Directorate of Medical and Health Services
gtzghp@eth.net, gtzbhp@vsnl.net, Ph: 020-26139762 Max Health Carte Institute Ltd., Max House Ph: 011-26589647(O), 011-28537087® )
Swasthya Bhawan, Tilak Marg, C-Scheme Jaipur, Rajasthan
Dr. Gopa Kumar STORJ@tbcindia.org, Ph:01412222422,9414269602 1,Dr. Jha Marg, Okhla Phase III, New Delhi 20 Dr. H. K.Chaturvedi
ECTA State Facilitator, Jharkhand ssingh@maxhealthcare.com, drshubnumsingh@gmial.com Asst. Director
Dr. B.R. Kashyap Ph: 91 011 51612123, 09810257949(M)
Govt. Vaccine Institute, H & FW Deptt. National Institute of Medical Statistics
Epidemiologist
Govt. of Jharkhand, Namkum, Ranchi Dr. Siddhrath Agarwal Indian Council of Medical Research
Directorate of Health Services
Jharkhand- 834 010 Country Representative, Environment Health Project Ansari Nagar, New Delhi- 110 029
Himachal Pradesh, Shimla
drgopakumar@vsnl.net 0651-3352165 (M), 06512261050 F9/4 Poorvi Marg, Vasant Vihar, New Delhi Ph: 09871176904
Ph: 95177-2628399 (O), 09418001876 (M)
Ms. Sabari Kar Gupta ephindia@mantraonline.com, Ph: 011-26149771 /81(O) Shri Vikram Anand
Shri Rajesh Jha
Programme Officer Dr. Sanjeev Upadhyaya General Manager -Operations
Vice President
Indo German Health Programme Consultant-Public Health HOSMAC India Pvt.Ltd. 1019, Galleria, D.L.F.City,
EPOS Health Consultants
Institute of Health & Family Welfare, GN- 29, Sector V Extn. 241, Urban Health Resource Centre Phase IV, Gurgaon 122002
Eastern India Regional Office
Bidhan Nagar, Kolkata- 700 091, West Bengal F-9/4, Vasant Vihar, New Delhi vikram.anand@hosmac.com
GC- 100, Ground Floor, Sector-3
sabari71@yahoo.com, skargvpt.ighp@gtzindia sanjeev@uhrc.in, Ph: 011-51010920, 26149771/ 81 Ph: 0124- 5043707, 9810802817
Salt Lake City, Kolkata- 700 106
Ph: 094331-45806, 03323574695 /96 /97
rajeshjha@epos.in Dr. S. Kaushik Dr. A. Venkat Raman
Dr. G. Hymavathi Ph: 033- 232116360, 9830709960 Research Specialist Associate Professor
Joint Director/ State Programme Officer Urban Health Resource Centre, Faculty of Management Studies
National Programme for Control of Blindness F-9/4, Vasant Vihar, New Delhi. University of Delhi South Campus
Directorate of Health, Hydebabad- AP. Kaushik@ehpindia.org, Ph: 011-5101092026149771/ 81 Benito Juarez Road, New Delhi-110 021
Ph: 09849902210, 04024600287 avr_fms@yahoo.co.in, venkatfms@yahoo.co.in
Ms. Anagha Khot
National Conultant, HSD, WR India Ph: 011- 24113353 (O), 011- 24110587 (R)
WHO Country Office, Nirman Bhawan, New Delhi. Dr. Gurpreet Singh
Anagha_khot@rediffmail.com Incharge MIS Cell
Ms. Preeti Anand IPP-8, Municipal Corporation of Delhi
Manager -Coordination, Janani, 4th Floor, Vigilance Building
12/1, First Floor, Nehru Enclave (East) 16, Rajpur Road, Delhi
New Delhi-110 019. drgps@yahoo.com, Ph: 011-23798509 (O)
preeti@janani.org(091-11) 26232223
Dr. Sunita Reddy Dr. Shampa Nag Officials from Ministry of Health & Research Scholars
Asst. Professor, CSMCH/SSS Social Scientist Family Welfare (MOHFW)
Jawaharlal Nehru University, New Delhi 110 067(R) Directorate of National Vector
sunitareddy@mail.jnu.ac.in Borne Diseases Control Programme Dr. R. K. Srivastava Shri. Sigamani P.
011-26704420011(O), 26192248(M), 011-9818858383 22Shyam Nath Marg, Delhi- 54 Director General of Health Services Faculty of Management Studies
Dr. Kirti Bhushan Rev. Arthur R. Pinto Ministry of Health & Family Welfare Delhi University
CMO (Mother NGO Scheme) Director Nirman Bhawan, New Delhi. siga.jnu@gmail.com
Directorate of Family Welfare Holy Family Hospital, Okhla Road
Government of N. C. T. Of Delhi New Delhi- 110 025 Shri. B. P. Sharma, IAS Ms.Shashi Rani
Malka Ganj, Delhi 110 007 apinto@bol.net.in, arthurpinto@hotmail.com Joint Secretary FMS,
diredfw@hub.nic.in, Ph: 9811066747(M), 011- 26194691 Ph: 011- 26845900, 011- 26914032 Ministry of Health & Family Welfare Delhi University, South Campus
Nirman Bhawan, New Delhi. New Delhi.
Prem. P. Talwar, Ph.D Dr. J. P. Steinmann
Chairman, MODE Services Pvt. Ltd. Programme Director Health Shashibhel@rediffmail.com, Ph: 9868088449
Dr. Tarun Seem
(A MODE Group company) Indo German Health Programme Deputy Secretary Ms. Shruti Joshi
L-7, Ist floor, Green Park Extension D- 108, Anand Niketan Ministry of Health & Family Welfare CPS, JNU
New Delhi- 110 016 New Delhi- 110 021 Nirman Bhawan, New Delhi. New Delhi-110 067
pp.talwar@mode_india.com, Ph: 011-51756793-96 jp.steinmann@gtz.de Maums_5@yahoo.com, Ph: 9818562585
Dr. Y.S. Kusuma Ph: 011- 24117267/73 Dr. Sunil S. Raj
Assistant Professor Ms. Barkha Goel Consultant, IDSP Ms. Jaya Drona
Centre for Community Medicine Programme Officer Directorate General of Health Services IIMC, Aruna Asaf Ali Marg
AIIMS, New Delhi- 110 029 Indo German Health Programme Nirman Bhawan, New Delhi. New Delhi- 110 067
kusumays@sify.com, Ph: 09810930031 (M) D- 108, Anand Niketan jayadrona@yahoo.com, Ph: 9868189595
Dr. G.P.S. Dhillon
Dr. Anil Goswami New Delhi- 110 021
DDG (L) Ms. Indulekha Aravind
Sup. MSSO bgoel.ighp@gtzindia.com
Directorate General of Health Services IIMC, Aruna Asaf Ali Marg
Centre for Community Medicine Ph: 011- 24117267/73
Ministry of Health & Family Welfare New Delhi- 110 067
AIIMS, New Delhi- 110 029 Dr. Praneet Kumar Nirman Bhawan, New Delhi. indulekha_aravind@yahoo.com
Anilgoswami55@hotmail.com, Ph: 09810776877(M) Director Projects
Dr. Mini Sood Future Health Care Ltd. Dr, S. K. Chaturvedi Ms. Gauri Parasher
Prof. UCMS and GTB hospital B-9, Maharani Bagh, New Delhi- 65. Jt. Director (CGHS) IIMC, Aruna Asaf Ali Marg
Shahadara, Delhi- 96 Dr. Anuj Srivastava Directorate General of Health Services New Delhi- 110 067
drminisood@hotmail.com, Ph: 09811652966(M) Urban Health Planning Specialist Ministry of Health & Family Welfare gparasher@yahoo.com, Ph: 9818391185
Urban Health Resource Centre Nirman Bhawan, New Delhi.
Dr. H.K. Chaturvedi Ms. Nitu Singh
Asstt. Director F-9/4, Vasant Vihar, New Delhi. Smt. Ganga Murthy 223, Sabarmati Hostel
National Institute of Medical Statistics Asrivastava@uhrc.in Economic Adviser JNU, New Delhi-110 067
ICMR, Ansari Nagar, New Delhi. Ph: 011-51010920, 26149771/81 Directorate General of Health Services Nitunitusingh@rediffmail.com, Ph: 986847631
Chaturvedi_icmr@yahoo.com Ministry of Health & Family Welfare
Ph: 011-26588803, 09871176904 Nirman Bhawan, New Delhi.
Shri. T.V. Raman
Director (AP)
Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi.
Dr. (Mrs.) R Jose
DDG (Ophth)
Directorate General of Health Services
Ministry of Health and Family Welfare
Nirman Bhawan, New Delhi.
Dr. P.P. Mandal
Chief medical Officer (NFSG)
Central TB Division, Directorate of Health Services
Nirman Bhawan, New Delhi.
 Participants From NIHFW Post Graduate Residents at NIHFW

Prof. N. K. Sethi, Director Dr. Mithila, MD (CHA) 3rd Year

Prof. K. Kaliavani, Dean of Studies & HOD
Deptt. of Reproductive Biomedicine
Prof. M.Bhattacharya, HOD
Deptt. of Community Health Administration
Dr. Vanlalhriatpuii, DHA 2nd Year
Dr. Manoj Dhingra, MD (CHA) 2nd Year
Dr. J. B. Babbar, MD (CHA) 2nd Year

Dr. U. Datta, Reader & Acting HOD Dr. Ajay Handa, MD (CHA) 2nd Year
Deptt. of MCHA and Education & Training Dr. Chaman Prakash, MD (CHA) 2nd Year
Dr. Vivek Adhish, Reader, Acting HOD
Deptt. of Epidemiology
Dr. Sanjay Gupta, Sub Dean & Sr. Lecturer
Deptt. of Community Health Administration
Dr. V. K. Tiwari, Sub Dean and Acting HOD
Deptt. of Planning & Evaluation
Dr. Gita Bamezai, Reader
Deptt. of Communication
Dr. P. Swain, Reader & Acting HOD
Deptt. of Statistics & Demography
Dr. Poonam Khattar, Reader
Deptt. of Education & Training
Dr. Hemanta Meiti, Lecturer
Deptt. of Statistics & Demography
Dr. T. Bir, Reader
Deptt. of Social Sciences
Dr. Y. L.Tekhre, Reader
Deptt. of Social Sciences
Sh. J. P. Shivdasani, RO
Deptt. of Planning & Evaluation
Dr. K. S. Nair, ARO
Deptt. of Planning & Evaluation
Shri. K. L.Gaba, Consultant
Deptt. of Planning & Evaluation
Shri. Pardeep Kumar, RA
Deptt. of Planning & Evaluation