Summing Up

Acknowledgments

Rapporteuring team

Presenters

Participants

Definition of PPPs

Ideological debate: Relation between market and state.

Dominance of new public management in HSR

Key operative terms in looking at PPPs: Accountability, Effectiveness and Regulation

Why PPPs (Dr Raman): to assist in furthering state’s goals

REDUCE OUT OF POCKET EXPENSES – EQUITY REACH OUT INACCESSIBLE AREAS/ GROUPS –

ACCESSIBILITY MORE SOPHISTICATED / TECHNOLOGY INTENSE

CARE – QUALITY COST EFFECTIVE – EFFICIENCY CONTROL IRRATIONAL BEHAVIOUR – REGULATION DEPLOY MORE FOCUSED RESOURCES -

INVESTMENT

Conceptual framework for looking at PPPs: one of them proposed was “role-authority and power”

Concerns related to PPPs: Lack of clarity between commercialization and PPPs. Delineation between public and the private- lumping of

private players. Values would be different for NGOs (not for-profit) and the for-profit private sector.

Unequal partners- is it partnership or engagement with the private sector or just a business relationship

Privatisation /PPPs Plurality of models Lack of evidence

What is available is descriptive and case studies - no impact assessment - no evaluation of impact on equity and access at

both micro and macro levels. Much of the debates are ideologically driven and

polarized: either market driven or skeptical about commercialization

The issues plaguing each of the sectors: Public- corruption, governance, accountability, lack

of evidence-based reform.Private- no regulation, gross violations, malpractice,

Conflicts of interest

Crucial requirements Monitoring and evaluation of contracts Independent regulatory system for

oversight Explicit, transparent and adequate

governance mechanisms Social safety measures for protection of

the vulnerable sub-sections

No universal approach to the issue will work.

Impact on public health sector needs to be studied

Nature of contracts needs to be studied

Role of NGOs as private players: Running services, capacity building, infrastructure Sustainability?? Challenges to scaling-up: NGOs working within

the public health system Vs NGOs working in isolation (islands of excellence)

Role of leadership at the level of NGOs and State

Driven by International Donor agendas: focus on vertical programs and state disinvestment or withdrawal from services (in the context of a history of international ‘economic’ reforms).

Role of Co-operatives

Strengths: network, reach Limitations: lack of professionalism, poor HR

management

Public Co-operative Private

PPPs under NRHM State is flush with funds but low absorption capacity Hasty planning, no market survey PPPs seen as panacea, transferring all responsibilities Directive rather than dialogue Changing guidelines, wandering bureaucrats No mutual trust, political interference Need for capacity building of state Does the State know what it is getting into? Lack of monitoring Limited reach, limited scope Cash assistance rather than service provision Insufficient compensation

Regulation Monitoring system (are the objectives really met at

the field level?), regulation/accreditation and accountability for both public and private players

Raising “performance: equity, quality and efficiency” Can it lead to compromised autonomy and ability to

innovate? Transparency enhancement to ensure engagement

for public purposes Contract management & Clarity of ownership Costing Gray areas in the area of Provision, Financing as well

as Governance & Stewardship Role of legislation but also enforcement Role of the private purchasers of care (IRDA)

Gaps …………. Available evidence: Descriptive- case specific, Few studies

under NRHM throwing up issues related to the top-down approach.

Lack of information among researchers, policy makers and beneficiaries about the schemes.

Need for studies looking at impact on access and equity rather than micro analysis (especially before we scale up ‘successful’ schemes.

Need to look at impact on the public health services (shortage of HRH, brain drain)

Compare certain PPPs like Chiranjeevi (bunched payment for purchase of care) and Yashasvini (insurance model) to understand impact of these especially over the long term

Contracting is one of the most common forms of partnership but requires further investigation (Bhabha)

PPPs: elephant in the room and blind men/women Is the elephant itself also blind

Is the elephant providing free rides to the people, paid rides or discounted rides to the local hospital for sight restoration procedures

Are these rides a precursor to being partially or fully trampled subsequently or to a stage where neither the people are blind nor rides are needed.

Thank You