Having undertaken this course in the “Policy and Practice Track” I intend the presentation to be of value to policy makers and ground level stakeholders in the healthcare sector. The main purpose of the presentation was to provide the major challenges and opportunities for Healthcare PPPs in the Indian context. I envisage it to be of help for government agencies as well as private healthcare players. It would also be helpful to researchers and NGOs who are working in the healthcare sector. The presentation dives deep into the different PPP models and highlights some of the success stories under each model. It also touches upon certain key risks and drivers of success under challenging circumstances.

1. PPP Solutions for healthcare in India
Saurav Kumar Das

2. 2
Access to specialty healthcare, advanced diagnostics
86 hospital beds / 1000 population – heavily skewed, the metro areas (6% of
population) account for 25% of hospital beds
Travel upwards of 90 km to access specialty care
Strong private sector - 64% of all hospital beds, 80% of outpatients and 57% of
inpatients receive treatment from private hospitals
Affordability and equity
One of the world’s highest levels of private out-of-pocket financing of medical
expenses, at about 85 percent, with debilitating effects on the poor - 35% of
hospitalized patients fall below the poverty line because of hospital expenses
Public spending on health has remained stagnant at around one percent of GDP
(0.9%)
The poorest quintile of the population uses only one-tenth of the public (state)
subsidies on health care while the richest quintile accesses 34 percent of these
subsidies
Critical workforce shortages
India is short of 600,000 Doctors; 1,000,000 nurses and 200,000 dental surgeons,
only 0.9 doctors and 1.2 nurses for every 1,000 Indians

3. Source: National Health Accounts Report 2004-05 of MOHFW/GOI.
(With Provisional Estimates from 2005-06 to 2008-09)

4. PUBLIC
SECTOR
PRIVATE
SECTOR

Free Provision of Products
 and Services
Unsustainable for Government &
Donors
Unsustainable for Consumers
Profit Maximization
Break Even





5.  Develop strategies to utilize untapped resources and
strengths of the private sector
 Reducing financial burden of government expenditure
 Reaching remote areas & target specific group of
populations
 Improving efficiency through evolving new management
structures

6. 6
 Payment delays
 Differences in Operating styles and trust level
 Local political interference
 Non-revision of contract clauses (Tariffs)
 Lack of capacity or willingness to supervise / monitor
/ guide the project
 Negative attitudinal orientation towards private sector

7. 7
 Half hearted government support for PPP
 Top officials are enthusiastic, but lower level officials
suspect PPP as ‘privatization’ or show disdain towards
the private provider
 Need for technical / managerial skills for designing,
negotiating, implementing and monitoring PPP
contracts
 Develop institutional capacity at all levels

8. 8
 Defining and verifying beneficiaries (BPL patients)-
especially high cost services
 Defining Quality or Performance or Outcome
indicators
 Efficient Supervision and Monitoring mechanism
 Timely revisions / updating of contract
 Ombudsman for dispute settlement
 Clarity on setting user fee

9.  Franchising & Social marketing
 Contracting out & Contracting-in
 Joint ventures
 Voucher schemes
 Running mobile health units
 Community based health insurance
 Involving professional associations

10.  Franchising: Franchise is a business model where the
franchiser grants exclusive rights to franchisees to
conduct business in a prescribed manner over a specified
period. The franchisees contribute resources of their own
to set up a clinic and pay membership to franchiser
 Social Marketing: Application of marketing techniques
to achieve a social objective. Associated with expanding
access to contraceptives and medicine. It intends to
increase the available products, including oral
rehydration solution, IFA tablets and other health
products to make marketing more self-sustaining.

11.  Janani social marketing and social franchise program
 Non-profit organization that provides family planning
and maternity care services in the states of Bihar,
Jharkhand and Madhya Pradesh.
 It combines social marketing with a clinic-based
service delivery program and a franchisee program
through which doctors in rural areas provide low-cost
services.
 Family planning and reproductive health services
through Surya Clinics.
 Titli centres sell condoms, pills and pregnancy test kit

12.  Contracting out: Refers to situation in which private
providers receive a budget to provide services and
manage a government health unit.
 Vacancies for a long period, high absenteeism, and
consistent low performance could be the critical criteria
to identify those government health clinics that need to
be contracted out
 Contracting In: Hiring of one or more agencies or
individuals to provide services.

13. Example of contracting out:
 Sawai Man Singh Hospital in Jaipur has contracted out the
installation, operation and maintenance of CT-scan and
MRI services to a private agency
 The agency is paid monthly rent by the hospital and the
agency has to render free services to 20% of the patients
belonging to the poor socio-economic categories
Example of contracting in:
 Hiring of medical specialists for certain days of the week in
Primary Health Centers (PHC) or Community Health
Centers CHC.

14.  Joint ventures are companies launched with
equity participation of government and
private sector.
 Example: The Rajiv Gandhi Super-specialty
Hospital in Raichur Karnataka is a joint venture
of Govt. of Karnataka and Apollo hospitals
Group, with financial support from OPEC
 The basic reason for establishing the
partnership was to give super specialty health
care at low cost to the people living below the
Poverty Line.
 The Govt. of Karnataka has provided land,
hospital building and staff quarters as well as
roads, power, water and infrastructure.
 Apollo provided fully qualified, experienced
and competent medical facilities for operating
the hospital.

15.  Govt. of Karnataka, Narayana
Hrudalaya hospital in Bangalore
and Indian Space Research
Organization initiated project
called ‘Karnataka Integrated
Tele-medicine and Tele-health
Project’ , which is an on-line
health-care initiative in Karnataka.
 Tele-diagnosis and consultation in
cardiac care and specialist care.
Free diagnosis, medicines and
treatment for BPL patients

16.  A voucher is a document that can be exchanged for
defined services as a token of payment
 The government offers vouchers at subsidized rates to
below poverty line people
 Packages can be bought, used when required and
ensures privacy for the client.

17. Chiranjeevi Yojna :
Concept
 A voucher system for the Below Poverty Line maternity population to
enable them to avail of private obstetricians in Gujarat
Design
 The Government deliberated the scheme with SEWA, the acclaimed NGO
and the Federation of Obstetric and Gynecological Society of India
(FOGSI), the professional organization representing practitioners of
obstetrics and gynecology in India, to devise a package rate for a delivery.
 The package included the weighted average of rates of a normal delivery,
complicated delivery, caesarian section, travel reimbursement to mother
and the accompanying trained birth attendant etc.
 A pilot project was conducted in five of the most backward districts
empanelling almost three-fourth of those districts’ private obstetricians

18. Innovation
 The doctors were paid a sum of Rs. 15000 in advance at signing of an
MoU, unlike most PPPs where payment comes in months after the
service has been delivered. This advance amount was to be topped up
after a certain amount of deliveries. Hence, the government always paid
for service in advance to gain credibility with the doctors
Results
 Between January 2007 and January 2010, about 4,35,047 safe deliveries
were carried out by 768 obstetricians.
 These represented roughly 55-60% of the total deliveries by the Gujarat
BPL population in this period.
 Over 26 months of the scheme, each doctor earned on an average almost
Rs.10 lakh, which is a fair amount of marginal income.
 Each pregnant woman, on the other hand, paid INR 654 on an average as
costs of medicines for the child and herself

19.  Vans go to identified central points on
fixed days and provide primary health
services to a cluster of villages.
 Vehicle, medical equipments, medicine are
provided by govt. and primary health care
services are provided by NGOs
 Bihar adopted the MMU scheme under the
name “Arogya Rath” in 2009 with three
private providers – Spake Systems, Jagran
Solutions and Jain Studios . The units
provide primary health care services free of
cost to people in underserved areas of the
state
 Madhya Pradesh adopted the scheme
under the name “Deen Dayal Chalit
Aspatal Yojana”

20.  Government pays health insurance premium for
families below poverty line. These families in turn are
insured against expenses on health and
hospitalization, up to a certain amount.
 Community members pay a minimum insurance
premium per month and get insured against certain
level of health expenditure
 Community based schemes ensure that local needs
and expectations of people are met

21.  Provides protection to BPL households
 Beneficiaries are entitled to get up to Rs. 30,000/- per
year
 Beneficiaries need to pay only Rs. 30/- as registration
fee while Central and State Government pays
premium to the insurer selected by State Government
on basis of a competitive bidding

22.  Unique community health insurance programme
through the Aarogyasri Health Care Trust
 The trust defines premium package, treatment protocols,
empanelment criteria
 A private insurance company/ Third-Party Administrator
(TPA), selected through competitive bid process , to
administer patient enrolment, hospital empanelment,
claims management, risk coverage
 Network hospitals, both public and private – strong
response by private hospitals to invest/move to district
and sub-districts

23.  Professional associations such as Indian Medical
Association, Gynaecologists federation, nurses
associations
 Extended help in launching new programmes such as
Vande Mataram Scheme
 Scheme of social franchising: Involving the interested
private practitioners to popularize contraceptives like
oral pills, emergency contraceptives and life saving Oral
Rehydration Salt (ORS) packets etc.
 Government facilities will be shared with the private
doctors on cost basis (e.g. X ray machines, laboratory
investigations).

24.  Public/private DOTS model established on pilot
basis in Hyderabad at Mahavir Trust Hospital
 Mahavir Trust Hospital acts as a coordinator and
intermediary between govt. and private medical
practitioners
 PMPs refer TB suspected patients to hospital
 Govt. benefits as DOTS medicines are not wasted

25.  Partnerships in Healthcare: A Public Private Perspective,
CII-Hosmac Whitepaper, 2010
 Public Private Partnerships for Healthcare in India, IFC
White Paper
 Issues in Health, Public Private Partnership, Ramesh Bhat
(December, 2010) Economic and Political Weekly Paper
 Public and Private Roles in Health: Theory and Financing
Patterns, Philip Musgrove (July, 1996). HNP
 Public-Private Partnerships & Collaboration in the
Healthcare Sector, Irina A. Nikolic and Harold Maikisch
(October, 2006). HNP

26. THANK YOU 