POP THE PPP PILL

It does not require genius to recognize that the state of health services in Uttar Pradesh is in bad shape, that there is urgent need to explore ways and means to frog-leap in this field. Aptly described being “caught in the gap between our dreams of greatness and the awful reality of our broken health system”, public-private-partnership (PPP or P3) holds promise to kickstart the process of recovery in our resource restricted state.

Where are we at present?

Despite our achievements on the economic and manufacturing fronts, India is lagging considerably behind in its health care, ranking 119 among 169 countries in the World Development Index, and Uttar Pradesh, with its highest density of population, is being ranked  4^th from the bottom among the 15 major states.

The health indices of Uttar Pradesh are well below the country’s average. Our Infant mortality rate (number of babies dying of every 1000 born, a sensitve indicator of the health services) for instance is 85, while Kerala’s is 17 and the country’s average is 58. Or if we look at childhood immunization, only 23 of every 100 1-year olds in the state received all the recommended doses compared with 90% in Kerala and a country average of 48.

How to catch up?

While the country’s healthcare needs much catching up, UP needs to act with even greater urgency if it wishes to erase its dubious distiction of being a lagard. Health-care needs prioritization and needs adoption of an apt slogan for holistic development “roti, kapda, makan, swasth and shiksha”, rather than short-sightedly clamouring for just the 1^st three.

The 3 pillars of healthcare that need bolstering are: money, infrastructure and manpower. The 3 props that can keep the pillars steady are sensible planning, effective execution and vigilant monitoring, things that don’t always come in abundant supply in a state government’s health machinery.

There is no disputing that our health-care sector needs considerable infusion of funds. The government’s present spending on health is 0.9% of the GDP compared with 9% in UK and 16% in the USA. Even if a 3-fold increase occurs as planners are promising, to 4% of GDP, a large gap will still remain between the country’s health needs and funds, as both medical technology and people’s expectations will continue to soar with time.

Public-Private-Partnership (PPP) is a model in which a government service is funded and operated by private players in partnership with the government, and seems particularly promising when a large gap exists between a state’s resources and its needs.

PPP in the health sector has success stories to tell. The best known example is that of the Human Genome Project, a mammoth research venture under the leadership of the National Institute of Health (government agency of the USA) that was initiated to unravel the human genetic code in a span of 10 years. A very successful partnership with a private organization, Celera Corporation, led to infusion of expertice and innovation, and the project finishing 2 years ahead of time and as a thumping success.

An example closer home was installation of an expensive MRI scanner at the Sanjay Gandhi PG Institute in several years ago during a cash-starved phase of the institute’s history. This machine provided much needed service that a tertiary care hospital needed to provide to its patients, and with its maintainance in the private company’s hands, had a strikingly low down-time. The money that gathered from the investigation charges was shared by the institute and the leasing company in a pre-determined ratio and to the satisfaction of both.

What are the types of PPP? There are broadly 2 types of private players: the philanthropic or non-profit ones who do not seek monetary profits, and the commercial ones who invest money in the PPP model with profit as the motive.

Several non-profit organizations operate globally or nationally and can be tapped in the state to improve our health services. The lsit is long and includes examples like the PATH Malaria Vaccine Initiative (MVI), Drugs for Neglected Diseases Initiave (DNDI), Global Alliances for Vaccines and Immunization (GAVI), World Health Organization (WHO), UNICEF, Bill and Melinda Gates Foundation, Bristol Myers Squibb Foundation, Coalition for Eradication of Viral Hepatitis in Asia Pacific (CEVHAP) and HOPE Initiative.  For the government to engage actively with these organizations, invite them to operate and deliver in this region, and get into partnership with them makes good sense. As they do not run for profit, and have global accountability standards, they make safe partners and bring in modern expertice apart from the much needed resources.

PPP with the corporate sector is however a different ball game, and needs to be evaluated with caution as the private partner’s driving motive in investing money is financial profit, and the money needs to be genearted from the users, who are residents of the state, and often usually poor.

Some dependence of PPP is however inevitable as the there is not a country in the world where healthcare is financed entirely by the government, and, while health is widely recognized a s a responsibility of the governement, private capital and expertice are increasingly being welcomed to bring in efficiency and innovation. India’s health care industry is a mamoth $ 17 billion, and is growing at 13% annually. Like it or not, the private sector, though largely unregulated and disorganized, , is already providing 80% of our health care services.

PPP ventures have seen, in different states of India, creation of hospitals, running of some aspects of health services, installing and running of equipment, running ambulance services, training manpower and many others. And few of them, to be fair, have done well.

Many have however run into disrepute or loss, reasons for which, analysis shows, are major flaws in the props of planning, execution and monitoring. The implications of PPP in Health-care are somewhat different from that of building roads and bridges. While recovery of money is directly from the end-users in those who use the latter facilities, it is only on the advice of doctors that people use the former; leaving decisions entirely to their discretion without a close watch may pose danger to the vulnerable public.An Ultrasopund machine installed and run by a corporate PPP model, for instance, had many more tests done than were genuinely required, suggesting the possibility of inducement-generated referrals. This assumes significance in India as more than 75% of the expenses are out-of-pocket of citizen with limited means.
Conclusion

Health care needs urgent prioritization in the state, and PPP holds tremendous promise in helping the state fortify the much needed 3 fractured pillars of its healthcare. Attracting the non-profit organizations should be a priority. Considerable proficiency and wisdomare however requiredin planning, executing and monitoring partnership with the corporate sector, in drawing investments in the state, but also ensuring that the services run smoothly and deliver results that benefit the state’s people.

As published in Hindustan Times dated 8 January, 2012.