by Deepak Mili

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Public Private Partnership in Health An
Understanding of PPPs in Primary Health Care in
Arunachal Pradesh

• by Deepak Mili
• Integrated Mphil/ PhD
• Tata Institute of Social Sciences, Mumbai

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Background

• Arunachal Pradesh is a vast hilly area spread
  over 83743 sq.km. in the north eastern part of
  India.
• Absence of the private healthcare sector,
  especially in remote and rural areas.
• The Government of India is interested in
  exploring ways to partner with the private sector
  to improve health outcomes for the poor. 

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Rationale of the Study

• For people living in interior rural areas,
  lacking economic and social mobility, primary
  health is the only available form of health care.
• Locational disadvantage of sub centres, PHCs,
  CHCs due to mountainous terrain and sparsely
  distributed tribal population in forest and hilly
  regions..
• Active participation of the Civil Society and the
  community in improving Health Care delivery
  system.

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Objectives

• To find out reasons for involvement of NGOs
  through PPP in running PHCs in Arunachal
  Pradesh.
• To understand the process of implementation of
  PPP in the context of roles and responsibilities
  of various stake holders in running PHCs in
  Arunachal Pradesh.

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Sampling Design

• The universe of the study was comprised of the
  people living in and around the catchments area
  of the six districts of Arunachal Pradesh. These
  six districts are as follows
• Deed Neelam PHC, Lower Subansiri District.
• Gensi PHC, West Siang District
• Lumla PHC, Tawang District
• Nacho PHC, Upper Subansiri District
• Sille PHC, East Siang District
• Thrizino PHC, West Kameng District
• Sampling Technique Convenience sampling

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• The numbers of PHCs that were handed over to
  different NGOs are as follows
• Karuna Trust, Karnataka
  9 PHCs
• Voluntary Health Association of India 5 PHCs
• Prayaas, New Delhi
  1 PHC
• Future Generation, Arunachal Pradesh 1 PHC

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Method of data collection

• Interview schedules were used for people living
  in the catchments areas of the PHCs and semi
  structured interviews were used with key
  informants at State, district, Sub division and
  Circle level. The key informants included
• District Medical Officer of the Six Districts
• District RCH officer of the Six Districts
• Medical Officer of the PHC
• Sub divisional Officer /Circle Officer/ Gram
  Panchayat member of the area where PHC is
  located.

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PPP in Operation

• For operating the PHCs the government provides
  90 of the funds of medication and staff
  salaries. (Rs.28, 34,172/ annum)
• The PHCs are responsible for providing the
  following services
• 24 hours Emergency/Casualty Services.
• OPD service for six days per week as per the
  timings specified by the State Government.
• 5 -10 bed inpatient facility.
• 24 hrs labour room and emergency Obstetrics
  facility.
• Minor Operation Theatre Facility
• 24 hrs Ambulance Facility
• Make available essential medicines as per the
  details at Schedule B of the MOU. The Agency
  would be encouraged to keep in stock such
  additional medicines as are found necessary after
  assessing the field situation.
• Participation in and implementation of National
  Programs of Health Family Welfare including the
  National Rural Health Mission.

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Monitoring Structure

• A PHC management committee was constituted at the
  PHC level comprising representatives of the
  Agency, DMO, District RCH Officer, DC or his
  nominee (not below the level of Circle Officer)
  and not more than three representatives from the
  Anchal Samitis in the Area.
• The local MLA of the area was a permanent Special
  Invitee to the PHC Management Committee.
• The Committee is scheduled to meet at least once,
  every two months and is responsible for
  guiding/monitoring the project.
• At the State level, a Steering Committee chaired
  by the Commissioner Secretary (Health) along
  with suitable representation from all stake
  holders including the Agencies, Central
  Government and other State Government Departments
  is formed.
• This State level steering committee is supposed
  to meet at least once, every three months.
• The model that is adopted in running PHCs in
  Arunachal Pradesh is contracting out model under
  which the whole PHC is handed over to NGOs.

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The Reality of Partnership in Arunachal Pradesh-
SWOT AnalysisStrengths

• Availability of at least one doctor in the six
  PHC areas were the study was conducted where
  previously no doctors were available on duty when
  the government was running the PHC.
• Availability of medicines in the PHCs presently
  being run by the NGOs and the indent of the
  medicine is made by the pharmacist in
  consultation with the Medical Officer (MO) of the
  PHC according to the needs of the PHC.
• Increase responsiveness of government health
  facilities to local needs through community
  involvement by formation of PHC Management
  Committee in each district which comprised of NGO
  staff, Member of village panchayat and district
  health authority.
• Increased competition by effectively ending
  governments monopoly on the provision of public
  services and introducing increased competition,
  contracting of PHC can drive down costs and
  provide an incentive for providers to explore
  innovative methods of service delivery. 

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Weaknesses

• Insufficient incentives as the present
  remuneration that was given to the PHC staff was
  same as that of government and no additional
  incentive was given to those posted in remote
  areas as a result a number of post varying from
  LHV to MO were lying vacant in the PHCs where the
  study was conducted.
• PPP is unequal as the Public sector is both judge
  and party and the NGOs who have taken over the
  PHC do not have much say in it.
• Sole dependence on the Project Manager who with
  his dynamic personality and commitment was the
  driving force behind the success of the programme
  till now. Such personality dependence of the
  programme is a major weakness and it may turn
  into threat anytime if such person happens to
  leave.
• The successful performance of the NGOs in PPP has
  created some prejudice in the minds of govt.
  officials who are being blamed for their lack of
  results. This has led to resistance and non
  cooperation from health officials to support the
  programme.
• Lack of support from other departments of
  district administration in implementing the
  programme.
• The NGOs has not shown enough commitment of
  resources to recruit full requirement of manpower
  and there are still vacancies in some PHC.

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Opportunities

• Indigenous system of medicine including herbal,
  traditional practices should also be taken into
  consideration indigenous health practitioners
  should be recognized and financially supported by
  the government. (MOHFW NHP 2002).
• The paramedical staffs posted at distant and
  geographically difficult terrains can be provided
  additional increments or incentives in order to
  attract them to serve in the rural and remote
  areas. These paramedical staffs can be recruited
  from the Paramedical Institute located in the
  East Siang district of Arunachal Pradesh.
• Currently government budgets are focused on
  inputs.  Money flows to health services on the
  basis of organ grams, seniority, size of
  establishment and previous expenditure patterns. 
  Well designed PPP programmes can allocate
  government funding on the basis of population
  needs, demand for services, quality of service
  provided and health outcomes achieved.
• International funding to PPP projects are very
  high. This can be utilized to channelize more
  funds to the project.

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Threats

• Inadequate education and awareness on PPP among
  the community leading to inadequate support and
  acceptance from the community.
• The posting of medical and paramedical staff at
  the PHCs and SCs should be based on the
  established norms rather than any other
  influencing factors or political pressure or
  nepotism.
• Accountability is an issue as the present MOs
  appointed by the NGO are accountable to the
  Project Manager of the NGO and are not
  accountable to the State Government. The PHC
  Management committee has been formed to review
  but it seems to be of not much help as far as
  accountability is concerned.
• Risk sharing is a crucial issue as currently the
  state government is offering 90 of the whole
  cost of this programme and the respective NGOs
  are pooling in 10 which may encourage even some
  inefficient NGOs to undertake the programme.
• Lack of sustainability is another threat as NGOs
  is running the PHC and tomorrow if the NGO leaves
  the project and goes away the community is
  presently not in a position to take up the
  responsibility.

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Recommendations

• The model requires an NGO that has the financial
  resources to complement the governments
  contributions.
• It is also essential that the NGO have full
  hiring and firing of staff.
• As most of the PHCs were located in the far flung
  areas and there was not even phone connection
  available in some of the PHC so in PHCs where
  phone connection is not available WLL phone
  should be provided to them which will be of great
  help for them.
• Unavailability of electricity supply in the
  PHCs. One of the PHC has set up solar plates if
  other PHCs can attempt to installs solar plates
  it will help a lot in running ILR and other
  important gadgets.

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Contd.

• As there are few villages which are not yet
  accessed by the present staff it will be a good
  idea to set up mobile clinics in places like
  weekly markets where these villagers from nearby
  areas come for marketing and can also avail
  health facilities.
• Introduction of Health Mela like the one
  conducted in East Kameng district in other
  districts also.
• Lack of sustainability is another issue if the
  NGOs maintaining the PHC decide not to continue
  the project and leave the community is presently
  not in a position to take up the responsibility.

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• Thank You for your attention.