Transcript PPP in Health: An understanding of PPP in PHC in AP

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 PHC’s in Arunachal
Pradesh.
• To understand the process of implementation of
PPP in the context of roles and responsibilities
of various stake holders in running PHC’s 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:
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2.
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4.
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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
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located.
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
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NGOs.
The Reality of Partnership in Arunachal
Pradesh- SWOT Analysis
Strengths:
• 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 government’s 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:
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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 NGO’s 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
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to channelize more funds to the project.
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 MO’s 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
NGO’s 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
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is presently not in a position to take up the responsibility.
Recommendations:
• The model requires an NGO that has the financial resources
to complement the government’s 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 PHC’s 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.
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