Guest Articles

April 5

William A. Haseltine / Rohini Kalvakuntla

How to Improve Public-Private Health Care Collaboration in India

In recent years, India has made rapid advances in improving health care. The National Health Mission has been instrumental in reducing maternal mortality rates in India by increasing its use of community health workers. It has also increased the number of individuals with government-sponsored health insurance, with more than 300 million people on some form of health insurance now, up from only 55 million in 2003-04. However, care in India continues to be highly fragmented with several pockets of inaccessibility and varying degrees of quality.

Increasingly, India needs to move toward a better-integrated care system where providers, both public and private, are aligned to provide the right care, at the right time and at the right cost. Public-private collaboration is critical to achieving this goal, especially considering that 80 percent of outpatient and about 60 percent of inpatient care is delivered by the private sector in India. The private sector has the capacity and capability to provide integrated care systems. But what will it take to align them to solving the critical challenges of public health? What will it take from the government perspective to encourage good practices in the private sector, reward innovation and partner to improve health outcomes of the country at large?

In practice, public-private partnerships are extremely complex to manage and often piecemeal in their approach. Particularly in India, governments turn to public-private partnerships to plug specific gaps that are beyond the scope of governments alone. There is a rising number of partnerships in diagnostics, the management of public health centers and hospital services, with defined roles and responsibilities for public and private sectors to accomplish the set objective. However, partnerships struggle because the public and private sectors lack trust and appropriate institutional mechanisms and structures to interact in a transparent fashion.

There is also often a lack of joint vision from both sectors. Partnerships must move beyond narrow definitions of plugging certain service delivery or performance gaps to create a common vision for universal health coverage in India, which promotes innovation, transparency and performance. This vision cannot be achieved without the critical role and collaboration of the public and private sector in planning. This demands moving away from the current government contracting the private sector, to government collaborating with the private sector.

Based on our experience in strengthening public-private collaboration in health care, we propose a few key shifts to improve public-private collaboration. This list is by no means exhaustive, but can be a good starting point.


Strengthen the government’s role as a ‘steward’ of the health system

The government must act as a steward for promoting good practices and curbing harmful practices in the private sector. The role of the government traditionally has been limited to the public health care system, with little oversight, collaboration and regulation of the private sector. This is not to say an absolute absence of policies, but an absence of suited policies and a plan to administer them. For example, a 2010 Clinical Establishments Act that was meant establish a minimum standard for all clinical facilities in the private sector is currently active only in four states. The effectiveness of the act in improving quality is still unknown. There is therefore a need for the government to better analyze the coexisting health markets before deploying appropriate finance or regulatory policy tools to steer the market in a suitable direction.


Improve public-private dialogue and the institutional framework for collaboration

Fundamental to public-private collaboration is the establishment of neutral and transparent platforms for dialogue between both sectors. The role of intermediaries or market facilitators can be useful to generate data for shared understanding between both sectors and foster meaningful dialogue. Such dialogues should be used by the government to articulate its vision, opportunities and challenges, as well as encourage ideas around areas of support from the private sector. The dialogues could range from broad-based trust building activities, to discussing specific goals and strategies to achieve set goals.

A well-thought-out framework for engaging the private sector should define the broad contours for the selection of private sector representatives, the management of partnerships, redressing grievances, and accountability for both the public and private sector. An empowered entity dedicated to public-private partnerships should be instituted to act as a single point of contact for all issues related to public private collaboration at the state and national levels.


Reward innovation and institute performance-based measurements

Moving the dialogue from inputs to outputs and outcomes is critical. A shift from measuring inputs like the number of staff, machines, beds or health centers to measuring outputs like percentage of population screened, average wait time to see a doctor or the number of drug stock-out incidences is critical to achieving results and aligning provider behaviors to better health outcomes. Strong data platforms and an accountability framework are critical to support this transition. On the government side, stronger governance structures must be created that base decisions on data and analysis linked to payments to ensure minimal delays.

In conclusion, India holds a deep potential and commitment to improve collaboration with the private sector to build integrated care systems. Pockets of experimentation are underway. One example is the comprehensive primary health care pilot in two blocks of Uttar Pradesh backed by the government of Uttar Pradesh and the Bill and Melinda Gates Foundation in collaboration with ACCESS Health International. It is important to get these partnerships right and learn from them to disseminate the learning and results widely for adoption. Practical experiences must inform the broader policy framework for private sector engagement in India.


William A. Haseltine is chair and president of ACCESS Health International and Rohini Kalvakuntla manages the Public Private Partnerships Project for ACCESS Health International.

Photo by UK Department for International Development via Flickr

Health Care
innovation, public-private partnerships, reproductive health