Karin Astrid Siegmann and Nazima Shaheen
Karin@sdpi.org
In a context in which the public sector has failed to offer satisfactory health services to people, partnerships between the private and public sector may provide hope. Such public-private partnerships (PPPs) typically involve a government agency interacting with a private partner. Partnerships may be created, for example, to renovate, construct, operate, maintain, and/or manage a health care-related facility or system, in whole or in part, that provides a public service. The private partner here denotes
both the for-profit sector as well as non-profit organisations. In order to assess the prospects and challenges of such collaborations, the Sustainable Development Policy Institute (SDPI), in co-operation with the University of Birmingham, UK, recently conducted a study of PPPs created to provide basic services in Pakistan. The study was based on a review of existing literature on PPPs in Pakistan as well as selected expert interviews. The current article is based on the findings of this study and its discussion at an SDPI seminar “Public-Private Partnerships in Health care: Prospects and Challenges” on September 18, 2006.
Pakistan's health services are characterised by three main problems, namely the rural and urban divide in terms of facilities; the low utilization of medical facilities, and last but not least, significant gaps in the national health services. Since the majority of doctors and hospitals are located in cities and towns, the rural population has much poorer access to health facilities.
The rural-urban disparities are compounded by gender gaps. Women and girls are more vulnerable than men and boys to injuries and sickness, in large part because of women's and girls' relatively poor access to health services, comparatively higher workloads and low nutritional status all of which are mediated by prevailing gender norms. Amongst others, they lead to complications of pregnancy and childbirth, which are the leading cause of death and disability among women of reproductive age. The maternal mortality ratio for Pakistan ranges from 340-700 per 100,000 live births as compared to 92 for Sri Lanka, for example. The absenteeism and lack of staff present at health facilities is another major problem, in turn decreasing their utilisation. Table 1 indicates that the existing health care infrastructure is capable of covering only a minority of the population.
Table 1: Selected public health care facilities by province (% of all villages)
| Punjab | Sindh | NWFP | Balochistan | |
| Government dispensary | 11 |
16 |
11 |
19 |
| Basic Health Units | 18 |
11 |
33 |
12 |
| Lady Health Worker | 16 |
3 |
21 |
2 |
Source: Federal Bureau of Statistics (2002)
The private sector plays a major and increasing role in provision of health care servcies. About 80% of the population access private health facilities. The quality of health-care provision is impaired by the fact that non-state providers (NSPs) are effectively unregulated. Especially in rural areas, it is common that persons having exposure to medical procedures while working as a dispenser, compounder, nurse assistant, or an assistant in a pathological laboratory open clinics, dispense medical advice, and prescribe medicines.
It is against this bleak background that major policy documents encourage PPPs for health care provision. For the improvement of health outcomes, both the Poverty Reduction Strategy Paper I (PRSP I) and the National Health Policy 2001 state that it is necessary to institute PPPs, for instance, by transferring un- and under-utilised health facilities, such as basic health units (BHUs) and rural health centres (RHCs), to NGOs, local bodies, and to the for-profit private sector. Other examples for involvement of NSPs explicitly mentioned include NGO support for awareness-raising.
Large donors supporting health care-related activities in Pakistan, such as the World Bank, ADB, WHO, and USAID, stress the need to forge partnerships with the private sector in health care provision.
Already, some of the national programmes in primary health care, such as the programmes on malaria control, tuberculosis control, and HIV/AIDS control, are implemented through collaborations of state and non-state health care providers. SDPI found lively experimentation with public-private collaboration in primary health care.
The most important areas of partnerships identified can be clustered under the themes of social marketing in the area of reproductive health, communicable diseases control, and policy development: For example, NGOs would conduct trainings for for-profit private practitioners, clinics, and pharmacies on contraceptives and other products' use on behalf of the Ministry of Population Welfare. Or, the distribution of insecticide treated bed nets for the malaria protection in highly endemic areas through NGOs would support the Ministry of Health's 'Roll Back Malaria' Initiative. An NGO developed a National Action Plan for the prevention and control of non-communicable diseases, such as cardiovascular diseases, in a tripartite partnership with the Ministry of Health and the WHO.Contracting out of basic health units in district Rahim Yar Khan.
As suggested in the National Health Policy, however, the major instance of state/non-state collaboration in the area of primary health care in Pakistan has been in contracting out of health services, though. These include handing over of government facilities, such as BHUs, RHCs and hospitals, to NGOs. The World Bank has played the role of a catalyst for such contracting out.
The contracting out of BHUs in the district Rahim Yar Khan provides one case in point. Responding to the wide-spread failure of BHUs to provide health care services to the population sketched above, the Government of Punjab transferred administrative and financial management of 104 BHUs in district Rahim Yar Khan to the Punjab Rural Support Programme (RSP), a large NGO. This included the allocation of the full budget for the BHUs to the RSP. Thereby it provided a pilot initiative for the government's plan to contract out dysfunctional BHUs. Many of the Punjab RSP staff members involved in the project were former bureaucrats thereby decreasing the distance between the state and private actor. Whereas some members of the district government had reservations against the partnership, the district nazim was a strong supporter of the pilot initiative and enabled the collaboration. Clusters of three BHUs each were formed. A doctor employed by the Punjab RSP visits each BHU on a two day per week rotation cycle. Community and school health sessions were introduced for awareness-raising on health care issues.
The results of the initiative were mixed. Whereas overall utilization of the facilities' increased, poorer patients and those living far from the BHU were reached to an insufficient degree. Another problem encountered in the relationship between the public and private partner consisted of ambiguous reporting requirements. On the one hand, the Punjab Rural Support Programme was the doctor's employer, whereas at the same time, he or she was supposed to report to the Executive District Officer health.
The pilot has been replicated in eight other districts of Punjab until spring 2005. The decision to take it to national scale has been taken recently.
As in the example above, the most common division of roles between the public and private partner involve the state in some form with NGOs rather with community-based organisations or the for-profit sector. The government is directly or indirectly often the funder of service delivery as well as the provider of infrastructure, such as in the case of BHUs. Generally, NGOs are more commonly found in the role of managers of these facilities. NGOs are found to have strengths in community mobilisation and capacity building.
Figure 1: Actors' roles in collaborative health care provision
A gap appears to exist between the government and NGOs. It mainly consists of a wide disparity in power and other (first and foremost financial) resources between the state and NGOs. Whereas collaboration may lead to enhanced access to these resources for the NGO, like in the example of the Punjab Rural Support Programme, the state partner gives up resources or finds itself simply channelling donor funds to NGOs. At the same time, NGOs are aware of their dependence and vulnerability vis-à-vis the government, leading to mistrust described in several of the interviews conducted. The chequered history of state/private sector relations in Pakistan, exemplified in the nationalisation process of the 1970s, followed by calls for renewed NSP involvement in basic services provision, may help to explain the roots of this suspicion.
The lack of trust is mutual: Politicians and officials often mistrust NGOs' and for-profit organisations' motives. The provision of funds by a donor may at least ensure that financially, both the public partner and the NGO benefit and, thus, provide an incentive to join hands despite mistrust. Donors might be successful as 'midwifes', the question is, though, whether a collaboration that is externally initiated can be sustained.
Theoretically, collaboration can work based on the complementary competences of the state and non-state partner. The government has access to bureaucratic and technical resources whereas NGOs are better in needs assessments and swift in decision-making. Despite this, according to the key informants, 'partnership' or 'collaboration' are euphemisms for the observed interaction between the state and NSPs, if not myths. This assessment is partially associated with the fear of the (previously) implementing public actor at losing power and other resources. NGOs' size and access to financial resources strengthen their position in the unequal relationship and thus positively influences the success of the collaboration. Its size and financial strength might have played a role in the comparatively successful case of the Punjab RSP. As indicated above, donor involvement may thus be catalytic in many collaborations.
A bureaucratic attitude and procedures on the side of the state partner is found to be another bottleneck for successful collaboration. Regulatory procedures are more often than not misused to extract rents from the regulated. This leads to problems especially in those cases that subordinate private partners and financial flows to the government. As mentioned, sharing responsibility and decision-making evokes fears of loss of power.
Collaboration between actors with different comparative advantages requires transparency. The selection of contractors for delivery of services, for example, needs to be based on an objective, transparent bidding process. Otherwise even a clear contractual relationship will be flawed and users of health care services will suffer. The example given above is a case in point: The contracting out of BHUs in district RYK was not competitive.
Social capital in the form of trust, norms, and networks is identified as an important factor in the success or failure of collaboration. In an environment with few structural incentives for the government to join hands with the non-state sector for health care delivery, personal contacts and initiative matter. For instance, a progressive nazim as in case of RYK can make more difference rather than the department itself. There is a 'downside of social capital' as well. It may also lead to rent-seeking retired government officials who form their own organisations or enter NGOs in order to benefit from their contacts within the government.
In order to assess whether PPPs can address the multiple gaps in public health care provision, it is important to address the bottlenecks identified above and to build on the strengths of each partner. Additional issues that should be given due consideration include the following:
