Public-private Partnership in primary health care An analysis of PPP model in Karnataka, India
Item
- Title
-
Public-private Partnership in
primary health care
An analysis of PPP model in Karnataka, India - extracted text
-
2L
The Neo-liberal economic policies in 1980's lead to emergence of Pubicprivate Partnerships. The PPP became most popular after health sector
reforms in developing countries. Many state governments in India adapted
PPP policies to enhance the efficiency and quality of services in health
sector. The partnership formed between Government of Karnataka (GOK)
and Karuna Trust is also one of the successful model since 1996. This book
tries to analyses the partnership between the GOK and Karuna trust in
delivering primary health care. A honest attempt is made to address some
of the fundamental questions such as, what made GOK to contract out the
primary health centres to NGO? How the model is implemented? and also
evaluates current functioning of the model from the perspectives of
providers and beneficiaries. Success of the partnership also depends on the
sustainability, so researcher also tried to understand how model is
sustainable. The study tries to draw conclusion and make some valuable
recommendations for future PPP policies and to provide an insight to
researchers, academicians and policy makers in social sector.
a
-o
i
<3
nr
5
3
S
Sananda Kumar
Sananda Kumar
Mr. Sananda Kumar completed his Masters of Public
health in health policy, Economics and Finance from
Tata Institute of Social Sciences, Mumbai, India and
currently working as a consultant for RSBY under GIZ
RSBY Young Professional programme with
government of Himachal Pradesh, India.
Public-private Partnership in
primary health care
An analysis of PPP model in Karnataka, India
LAMBERT
978-3-659-21535-3
Academic Publishing
Sananda Kumar
Public-private Partnership in primary
health care
An analysis of PPP model in Karnataka, India
LAP LAMBERT Academic Publishing
Impressum / Imprint
Bibliografische
Information
der
Deutschen
Nationalbibliothek:
Die
Deutsche
Nationalbibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliografie;
detaillierte bibliografische Daten sind im Internet uber http://dnb.d-nb.de abrufbar.
Alle in diesem Buch genannten Marken und Produktnamen unterliegen warenzeichen-,
marken- oder patentrechtlichem Schutz bzw. sind Warenzeichen oder eingetragene
Warenzeichen der jeweiligen Inhaber. Die Wiedergabe von Marken, Produktnamen,
Gebrauchsnamen, Handelsnamen, Warenbezeichnungen u.s.w. in diesem Werk berechtigt
auch ohne besondere Kennzeichnung nicht zu der Annahme, dass solche Namen im Sinne
der Warenzeichen- und Markenschutzgesetzgebung als frei zu betrachten waren und
daher von jedermann benutzt werden durften.
Bibliographic information published by the Deutsche Nationalbibliothek: The Deutsche
Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed
bibliographic data are available in the Internet at http://dnb.d-nb.de.
Any brand names and product names mentioned in this book are subject to trademark,
brand or patent protection and are trademarks or registered trademarks of their respective
holders. The use of brand names, product names, common names, trade names, product
descriptions etc. even without a particular marking in this works is in no way to be
construed to mean that such names may be regarded as unrestricted in respect of
trademark and brand protection legislation and could thus be used by anyone.
Coverbild / Cover image: www.ingimage.com
Verlag / Publisher:
LAP LAMBERT Academic Publishing
ist ein Imprint der/ is a trademark of
AV Akademikerverlag GmbH & Co. KG
Heinrich-Bocking-Str. 6-8, 66121 Saarbrucken, Deutschland / Germany
Email: info@lap-publishing.com
Herstellung: siehe letzte Seite/
Printed at: see last page
ISBN: 978-3-659-21535-3
Zugl. / Approved by: Mumbai, Tata Institute of Social Sciences, 2012
Copyright © 2012 AV Akademikerverlag GmbH & Co. KG
Alle Rechte vorbehalten. / All rights reserved. Saarbrucken 2012
1
Contents
1. Introduction and Literature Review.
7-31
2. Conceptualization, Research Question and Objectives.
32-34
3. Methodology.
35-38
4. Analysis and Discussion.
39-79
5. Conclusion and Recommendation.
80-84
Appendix
i. Interview Schedule/Questionnaire.
85-93
ii. Memorandum of Understanding
94-112
References
113-116
' S0CH^\^
r.'
On?a''9«'»ia
dhchoo
^7-
2
List of abbreviations
AIDS:
Acquired Immune Deficiency Syndrome
ANC:
Antenatal care
ANM:
Auxiliary Nurse Midwife
ARS:
Arogya Raksha Samiti
AYUSH: Ayurveda, Yoga, Unani, Siddha, Homeopathy
CEO:
Chief Executive Officer
DHO:
District Health Officer
ECG:
Electrocardiogram
FGD:
Focus Group Discussion
GDP:
Gross Domestic Product
GNM:
General Nurse Midwife
GOK:
Government of Karnataka
HDI:
Human Development Index
HEWS: Health and Family Welfare Services
HIV:
Human Immunodeficiency Virus
HMIS:
Health Management Information System
HRD:
Human Resource Development
IMF:
International Monetary Fund
IMR:
Infant Mortality Rate
IPP:
Indian Population Project
ISRO:
Indian Space Research Organisation
JSY:
Janani Suraksha Yojana
3
KT:
Kanina Trust
LHV:
Lady Health Volunteer
M&E:
Monitoring and Evaluation
MCH:
Maternal and Child Health
MCI:
Medical Council of India
MMR:
Maternal Mortality Rate
MOU:
Memorandum of Understanding
NABH:
National Accreditation Board for Hospital and Healthcare Providers
NFHS:
National Family Health Survey
NHP:
National Health Programme
NRHM:
National Rural Health Mission
OPEC:
Organisation of the Petroleum Exporting Countries
PPP:
Pubic-Private Partnership
RCH:
Reproductive and Child Health
SDC:
Second Division Clerk
SPSS:
Statistical Package for the Social Sciences
SRS:
Sample Registration System
TB:
Tuberculosis
THO:
Taluk Health Officer
UN:
United Nations
UNDP:
United Nations development Programme
WHO:
World Health Organisation
ZP:
Zilla Panchayat
4
List of illustrations:
Figures:
1.
Figure 1.1: Infant Mortality Rate
21
2.
Figure 1.2: Organisational structure Karuna Trust
30
3.
Figure 2.1: Conceptual framework.
32
4.
Figure 4.1: Process of creating partnership
.42
5.
Figure 4.2: Awareness about PPP(P.N Halli).
47
6.
Figure 4.3: Awareness about the PPP(K. Halli)
48
7.
Figure 4.4: The major sources of funding for NGO
72
Tables
1.
Table 1.1: Health Infrastructure and Human resource in India.
17
2.
Table 2.1: India Public Health Expenditure trends (1975-2004)
19
3.
Table 1.3: Health Infrastructure Karnataka.
26
4.
Table 1.4: Health Indicators.
26
5.
Table 4.1: How beneficiaries come to know about PPP(P.N.Halli)
47
6.
Table 4.2: How beneficiaries come to know about PPP(K. Halli)
48
7.
Table: 4.3: Staff availability PN Halli
60
8.
Table 4.4: Statistics PN Halli
61
9.
Table 4.5: Quality of service provided (P.N. Halli)
62
10.
Table 4.6: staff availability K. Halli
63
5
11.
Table 4.7: Statistics K. Halli
64
12.
Table 4.8: Quality of service provided (K.Halli)
65
13.
Table: 4.9: Opinion about continuation of programme
76
14.
Table: 4.10: Measures to support the programme.
77
6
ACKNOWLEDGEMENTS
I am desirous of mentioning my profound indebtedness to Dr. Kanchan Mukherjee,
Associate Professor, Tata Institute of Social Sciences, my research guide for his
valuable advice, guidance, precious time and support he offered.
I would like to take this opportunity to thank Dr. Sudarshan for providing me an
opportunity to conduct my study with Karuana Trust.
I would also like to thank Dr. C.A.K Yesudian, Dean, School of Health System Studies,
Tata Institute of Social Sciences, Mumbai.
I hereby thank all the government officials who provided me their precious time,
relevant information without which I would not be able to complete this study.
I would be failing in my duty if I do not acknowledge my gratitude to Dr Ramanath
Ballala, Karuna trust who helped me in carrying out this study.
And most importantly, a special note of thanks to Dr. Rashmi for being around when it
mattered.
I also thank Mr. Manjunath for his support and suggestions during the course of the
entire study.
I would also like to thank all the employees of Karuna Trust for giving me their
precious time,relevant information and advice without which I would not be able to
complete this study.
Lastly I acknowledge my parents for their continuous blessings and love; I have no
words because they are the pillars on which I am standing.
7
Introduction and Literature Review
The health of any nation is the sum total of the health of its citizens, communities
and settlements in which they live. A healthy nation is, therefore; only feasible if
there is total participation of its citizens towards this goal. Ill health of the people is
not private, it is public, misfortune. The care of the sick people is not private
responsibility it is public. India is having wide mask of inequalities in health care
outcomes. The overall human development index is very low, as well as, there is
lot of disparities in the nation among the states itself. The India had come up with
several implicit and explicit policies since independence, but failed to bring equity
in health.
Since independence the government of India has taken several measures to
improve the health of all. Even though India is a welfare state, it is one of the
countries to adapt universal primary health care policies after the independence,
but it significantly failed to achieve the goal of health for all.
The delivery of public goods and services can be done in two polar ways i.e. direct
provision by governments and full privatisation of that. Due to increase in the
financial pressure on government prompted the expansion of new formulas that
allow the channelling of alternative resources, government tend to rely on market.
The ideological reason behind this is to better obtain value for money, i.e. improve
the efficiency. So, the public-private partnerships emerged as policy options in
delivery of services to improve the quality, efficiency and accessibility. Through
PPP the government enters into a long-term contract with a private partner to
deliver a good or service. The private partner is responsible for building, operating
and maintaining assets that are necessary for delivering the good or service.
8
This study deals with the Public-private partnership model providing primary
health care. This study trying to analyse the Public-private partnership formed
between Karuna Trus (NGO) and Government of Karnataka which is engaged in
providing primary health care.
Rationale of the Study
The primary health care is very essential to the people which has to be provided at
free of cost. It is the responsibility of the state to ensure the quality of care at low
cost. Due to meagre budget allocation and scarce resources the PHCs are handed
over to the NGOs to improve the efficiency, quality and coverage. Karuna trust is
one the NGO which has adapted Primary health centres to provide health services.
It was founded in 1986. It is presently managing nearly 30 PHC’s in Karnataka and
9 PHC’s in Arunachal Pradesh.
The study is conducted to explore the reasons behind the contracting out of PHCs
to the NGOs and to understand the motives behind it. The PPP in developing
countries is newer concept. It is very crucial to understand how these PPPs are
functioning and what are the implications. The study also tries to understand the
problems existing for the success of the partnerships.
The partnership with NGOs may involve negligible risk compared to that of for-
profit players. Partnerships with non-profit sector also face extensive challenges.
The sustainability of the partner is important for the success of the partnership. The
study also tries to understand how partner is sustainable.
The study is also conducted to investigate whether the terms and conditions on the
contract paper are really followed at ground level. It is very important to
understand, the benefits which are mentioned at the beginning of the partnerships
9
are delivered to the population. The study is conducted with all the purposes above
mentioned and to make policy recommendations for future PPP policies.
The concept of PPP
The Public-private Partnership in the health services can be described as a long
term contract between a public sector authority and one or more private sector
organisation operating as a legal entity. The government provides financial
support, outlines goals for an optimal health system, and empowers private
organisations to innovate, build, maintain and/or manage delivery of agreed-upon
services over the term of the contract. The government provides the payment for
the services of the private sector and private sector assumes the substantial
financial, technical and operational risk while benefitting from the upside
prospective of shared cost savings.
The concept of partnerships for development cooperation is not new. In the 1969s
itself, the Pearson Commission on International Development well thought-out the
nature of partnership between donors and recipient countries (Stephany Griffith-
Jones and Barbara Stallings, autumn 1995).
Although private firms have been involved in public service delivery for a long
time, the introduction of PPP in the early 1990s established a mode of public
service delivery that redefined the roles of the public and private sectors.
Throughout the 1990s and early 2000s, PPP has expanded in terms of the number
of countries where it is used and in terms of the number of sectors and projects
funded through this partnership as well. Governments introduced PPP for various
reasons: to improve the value for money in public service delivery projects, or
because PPP had the potential of bringing private finance to public service
delivery. Although, governments increasingly admit that PPPs are an instrument to
10
improve value for money, they do not necessarily consider them as an additional
source of finances. Nevertheless, there is still a lack of clarity about the definition
of PPPs as well as the relationships between affordability, budgetary limits and
access to private finance.
The proliferation of public-private partnerships is rapidly reconfiguring the
international health landscape. The latter half of the 1990s witnessed a burgeoning
number of initiatives involving collaboration between the corporate and public
sectors with the purpose of overcoming market and public “failures” of
international public health, using global public- private partnerships for health
development(K. Buse and G.Walt 2000).
During the past two decades, some countries have seen a huge increase in the use
of private-public partnership as a mode of public service. In the experience of most
countries, the trend has been to begin with PPP in the transportation sector and
then move gradually into other sectors. Other services that governments deliver
through PPP in the early stages of their use are water and waste management and
healthcare (Jose Luis Navarro Espigares, Elisa Hernandez Torres).
Risk plays a fundamental role in the success of a public-private Partnership.
Indeed, whether or not an activity is deemed to be a PPP or traditional procurement
primarily depends on who bears the bulk of the risk. The key to understanding the
role of risk in a Public-private Partnership is the link between the carrying of risk
and the efficiency of the project. The main rationale to enter a PPP agreement is
the possible improvement in service delivery and efficiency by the private partner
relative to what traditional procurement can deliver. In accordance with economic
theory, a distinction should be made between three kinds of efficiency: allocative
11
efficiency (i.e. the use of resources so as to maximize profit and utility), technical
efficiency (i.e. minimum inputs and maximum outputs), and X-efficiency (i.e.
preventing the wasteful use of inputs) (Jose Luis Navarro Espigaresl,2, Elisa
Hernandez Torres).
There is not a country in the world where the entire health care is funded by the
government. Since more than two decades public-private partnerships have been
used to finance health infrastructure. The trend of only financing is now changing
and governments are increasingly looking to the PPP-model to solve larger
problems in healthcare delivery.
At a more general level, engaging in a PPP process will require governments to
define clear legal and policy frameworks and to make certain that the appropriate
capacity exists within the government to initiate and manage PPPs.
In the health sector, WHO describes partnership as a means to “bring together a
set of actors for the common goal of improving the health of populations based on
mutually agreed roles and principles,”
The evolution of PPP
The collaboration between the public and private organisation was very minimal
until late 1970s with in United Nations or international development system. The
relationships were often uncompromising with little trust on either side. At that
time, the partnership was only limited to public sector relationships between the
donor agencies and the recipient country governments. Even though the UN
charter allowed for suitable arrangements for consultation with non-governmental,
not-for-profit organisations, the relationship between UN agencies and NGOs in
the 1960s hardly constituted partnerships.
12
The reforms happened in the health sector during the 1980s and 1990s brought
major changes in the health policies of developed as well as developing countries.
The word ‘reform’ before the structural adjustment programme came into exist was
referring to organisational changes in the provision of the health services i.e. for
examples importance towards primary health care over secondary care services.
But after introduction of the structural adjustment programmes by the Bretten
Wood institutions there was radical shift in the meaning of the word ‘reform.’ The
reforms were mostly associated with focused upon the economic value of the
health care services.
The World Bank’s structural adjustment lending has evolved over time, with initial
conditions varying between countries. While the content of structural adjustment
loans has been complex and varied, the basic model underpinning IMF/World
Bank orthodox lending has been similar. This could be broadly divided into three
central principles: reducing the role of the state relative to that of the private sector;
'getting the prices right’; and opening up the economy (Woodward, 1992).
During the 1970s, the share of funding to developing countries provided by private
sources grew rapidly, as did the share of international lending channelled by
international banks. Such 'privatization’ of a large proportion of development
funding was strongly welcomed by orthodox economic analysts as being the most
efficient way to finance development in Third World countries. The trend was also
encouraged by the IMF as a convenient mechanism for recycling funds from the
'surplus’ countries to oil-importing developing countries (Stephany Griffith-Jones
and Barbara Stallings autumn 1995). The funding for the developing countries
came from the international banks to improve the efficiency of the service
provided. But the soft loans are provided with certain conditionality’s which
leaded to change in policies, which imposed to introduction of the user fees, and
13
supported the marketisation of the health care. By the late 1970s and early 1980s,
as neoliberal ideologies influenced public policy and attitudes, relationships began
to change. Influential international organisations acknowledged and championed a
greater role for the private sector. Donors looked beyond the state for collaborators
in project work, and began to form broader relationships.
The structural adjustment policies strategy reinforced the governments to reduce
the financing share in the national budget in the social sectors. So due to this neo
liberal emphasis the investment in the developmental sectors in the developing
countries suddenly reduced as compared to previous budgets. So there was
increase in out of pocket expenditure in the health sector and the private sectors
become very dominant in providing the health service delivery.
The abundant literature on the financing and reorganisation of health care tends to
be limited to a techno centric approach. Advocates of health care reforms tend to
locate their arguments within the narrow confines of efficiency and effectiveness
(World Bank, 1993; Leighton, 1995). They depend heavily upon conventional
economic analysis which accepts market principles as the most rational means for
achieving efficiency in the developing world. It is common for such advocates to
emphasize terms such as 'demand’ and 'supply’ and the provision of consumer
'choice’, reinforced still further by the key words of 'efficiency' and 'cost
containment’ in the provision of health care (Kasturi Sen And Meri Koivusalo
1998).
There were structural changes in the organisation and delivery of health services in
order to include increased cost-sharing and increase the role of private providers
and practitioners (both profit and not-for profit). The new policies encouraged
14
market mechanisms in the health care provision and the health care has
commercialized.
World Bank's analysis of structural adjustment programmes in Sub-Saharan Africa
shows that the share of government budget allocated to the health sector fell during
the adjustment period in many countries (Kasturi Sen And Meri Koivusalo 1998).
The current debate of the role of PPP in the development process has its roots in
the discussion of a welfare reform in the industrialised countries, notably the US
and UK. The concept of PPP in itself is therefore not new and dates back to the
early eighties when Thatcher and Reagan took over the government in the UK and
the US respectively (Johannes Jutting 1999).
The health care market is different from other market. The asymmetric
information, imperfect competition, supplier induced demand, principle of equity
etc were the causes for the failure of the market. So the idea of complete
marketisation of health care which was advocated by the neoliberal economic
policies failed to prove their ideology. Instead, various quasi-market solutions were
developed, typically the separation of purchasers and providers within the public
sector. The logical next step was to move the delivery of healthcare out of the
public sector.
Evidence says that in most of the developing countries due to escalation of health
care cost most of people who fall seriously ill are pushed below the poverty line.
More over the health care reform failed to live up to their promise of improving
effectiveness, efficiency, equity in the health sector. Some World Bank economist
have pointed that the cost of the health care in the countries like Bangladesh and
India is a serious economic burden to the below poverty line families. In general,
15
the evidence on different aspects of health sector reforms do not reveal the positive
outcomes, either in economic terms or in terms of quality of care, projected by the
reforms. So, rapid privatization is evidently creating serious concerns about the
regulation and cost-containment of care; it requires governments to exercise
sophisticated administrative skills if equity and quality of services are to be
addressed. So the Bretten Wood Institutions came up with the new strategy of
Public-private Partnership policies to overcome problems and to achieve efficiency
in health care.
The countries using Public-private Partnerships are not limited to developed
countries, but also include several emerging market economies such as Brazil,
Chile, China and South Africa. In some of these countries, the implementation of
PPPs is well underway, though some of them are having problems. The initial PPP
experience in China highlights the fact that traditional joint venture frameworks
were badly prepared for PPP implementation (Jose Luis Navarro Espigaresl,2,
Elisa Hernandez Torres).
It is very abundant in the literature that public-private partnerships are also failed
to achieve their objectives to some extent in terms of efficiency and equity in
health service delivery. The Creese and Chabot describes in their publications that
in the past two years, World Bank prescriptions for health care reform have
expressed some ambiguity with respect to the policies promoted. How- ever, two
recent publications still continue to emphasize a clear commitment to the private
sector as the provider of public services (World Bank, 1997a, 1997b). The health
care policies proposed in these documents lend support to a diminished role for the
state in service provision with contractual arrangements as well as the
public/private mix in health systems. The problem with these policies is that in
16
practice they have not achieved the expected gains in terms of cost savings and
efficiency (Kasturi Sen And Meri Koivusalo 1998).
A systematic review identified 149 comparisons of for-profit and not-for profit
health facilities (of various types) undertaken over the past two decades in the
USA. Of these studies, 88 concluded that non-profit facilities performed better
with respect to cost, outcomes of care, access and social mission, 43 studies found
no difference, and 18 reported for-profit facilities to be better (Jose Luis Navarro
Espigaresl,2, Elisa Hernandez Torres).
Public-private partnership in the health sector can take a variety of forms with
differing degrees of public and private sector responsibility and risk. They are
characterized by the sharing of common objectives, as well as risks and rewards, as
might be defined in a contract or manifested through a different arrangement, so as
to effectively deliver a service or facility to the public. The private sector partner
may be responsible for all or some project operations, and financing can come
from either the public or private sector partner or both. This ideological shift is not
based solely on economic philosophy but also on changes to the prevailing
sociopolitical orthodoxy.
India- perspective of PPP
India is a country with full of resources and it is a fastest growing economy in the
world. It is the country with lot of diversity and inequity in intra state and
interstate. It has one of the world’s largest networks of health centres and hospitals
under a public health system.
Since Independence, India has built up a vast health infrastructure and health
personnel at primary, secondary, and tertiary care in public, voluntary, and private
sectors. For producing skilled human resources, a number of medical and
17
paramedical institutions including Ayurveda, Yoga and Naturopathy, Unani,
Siddha, and Homeopathy (AYUSH) institutions have been set up.
Current Health Scenario of India
Health Infrastructure and Human resource in India
One of the important indicators to understand the health care delivery provisions
and mechanisms in the country is Health Infrastructure. It also signifies the
investments and priority accorded to creating the infrastructure in public and
private sectors. The below data shows the current Health Infrastructure of the
country
Table 1.1: Health Infrastructure and Human resource in India
Indicator
1951-1952
2010-2011
Remarks
Population
361 million
1.21 billion
2011 census data
Sub-centres
Primary Health centres
145894
725
23391
Community Health Centres
4510
Allopathic hospitals
12,760
Except
Bihar
and
Jarkhand
All beds
117,178
576793
Doctors (allopathic)
61800
816629
Registered at MCI
752254
Ayurveda,
Doctors (Indian Systems)
Homeopathy
Nurses
16,550
1650180
GNMs only
Five-year plan budgets (million 653
rupees)
Medical colleges
30
314
Source: (National Health Profile 2010, India, A. Venkat Raman 2009)
Unani
and
18
The Table 1.1 represents the increase in the infrastructure over the years from
1950s to twenty first 2010. There is tremendous increase in the infrastructure,
human resources, expenditure etc. India is one of the largest medical graduates
producing country in the world. It is exporting large amount of nurses to the
different parts of the world. The paradox is still the country suffering with lack of
human resources due to uneven distribution.
The Bhore committee recommendation in the 1943 was of the essence for
improvement in the health status of the country. The committee has been headed
by eminent public health experts, who have studied the issues in an in-depth
manner and provided overarching recommendations for various aspects of the
health care system in India. The primary health care delivery structure came into
exist after the Bhore committee recommendations. The three tier health care
delivery system expanded in its infrastructure.
Socio-economic and health indicators
The life expectancy in India comparatively low with respect to other countries
belongs to the same basket. The average life expectancy at birth has increased from
59.7 yrs. For male and 60.9 years for female in 1991-95 to over 62.6 for male and
64.2 for female in 2002- 2006
Infant Mortality Rate has declined considerably (70 in 1999) during the last decade
and reached 50 per 1000 live births in 2009. However rural (55) & urban (34)
differentials are still high.
The maternal mortality rate in 2001-2003 was 301 and it is reduced to 254 by
2004-06. But it is very quiet high compared to other developing countries also like
Srilanka, China etc.
19
According to 2008 statistical report, Registrar General of India the Total Fertility
rate of India is 2.6. It varies between the rural and the urban. The fertility rate of
rural India is 2.9 where as it 2.0 in case or urban.
India has been performing poorly in social sectors. India’s rank in terms of the
UNDP Human Development Index (HDI) is 126 among 177 countries, which
manifests from a stagnant and declining share of social sector in total expenditure
of the Government.
Constraint factors (problems health system plagued)
Financing and Resource Constraints
Table 1.2: India Public Health Expenditure trends (1975-2004)
Year
Health Expenditure as a % of GDP
Per capita public expenditure on
health (in rupees)
1975-1976
0.81
11.15
1980-1981
0.91
19.37
1985-1986
1.05
38.63
1990-1991
0.96
64.83
1995-1996
0.88
112.21
2000-2001
0.90
183.56
2003-2004
0.91
214.62
Source: Cehat report, 2005
The Table 1.2 shows the India’s meagre GDP share on health expenditure. The
above table shows that since 1975 to 2004 the GDP share on health expenditure
remains stagnant at below 1 percent compared to global average of 5.5 percent.
The neoliberal policies of the World Bank and IMF restricted the spending on
health in India also. Comparison with other countries which are having almost
same socio-economic profile the India spending on health is very low.
20
In the allocation of the budget the most of the budget usually allocated towards
tertiary care rather than primary care which seriously impairs the equity and
efficiency of the public health system. Out of this public spending maximum
amount will goes to salaries and leaving little room for essential drugs, supplies
and maintenance of existing services (A. Venkat Raman and Bjorkman).
Worsening infrastructure
India’s healthcare infrastructure has not kept pace with the economy’s growth. The
physical infrastructure is woefully inadequate to meet today’s healthcare demands,
much less tomorrows. The large widespread health infrastructure that has been set
up throughout the country seems to be non-functional and unresponsive in many
parts.
While India has several centres of excellence in healthcare delivery, these facilities
are limited in their ability to drive healthcare standards because of the poor
condition of the infrastructure in the vast majority of the country.
Inequality Matters
When it comes to healthcare, there are two Indias: the country with that provides
high-quality medical care to middle-class Indians and medical tourists, and the
India in which the majority of the population lives—a country whose residents
have limited or no access to quality care (A. Venkat Raman & Bjorkman 2009).
Often this difference is so dramatic that one can hardly believe that they are part of
the same nation and have followed the same development path for the last five
decades. Even within the states that are doing reasonably well, there remain
regions of darkness where little has changed since Independence.
21
Figurel.l: Infant Mortality Rate
■ NFHS-2
■ NFHS-1
85
79
62
56
47
42
I |j
lif
Ma
5J
Urban
■ NFHS-3
68
57
18
toRural
Total
Organisational and Managerial Challenges
The Indian health system is plagued with organisational and Managerial
constraints. The public institutions of health care delivery lack institutional
capacity, resource allocation, quality and performance standards, management
systems and better governance.
Many public health centres are not fully functional due to shortages of staff, drugs
and equipment, prolonged delays in recruitment, corruption and political
interference in postings and transfers, inadequate incentives, career stagnation,
unfavourable working conditions, high workload and poor supervision have all
contributed to low morale, absenteeism, unionization and poor performance among
health workers. HRD policies are needed for recruitment, posting, promotion and
transfer, incentives, training and professional development. The demoralization
that exists among the workforce must be countered by enhancing professional and
career opportunities (A. Venkat Raman 2002).
22
PPP scenario in India (Health Sector reform and PPP invasion)
The need for public-private partnerships arose against the backdrop of
inadequacies on the part of the public sector to provide public good on their own,
in an efficient and effective manner, owing to lack of resources and management
issues (Sania Nishtar 2004). Public-private partnerships have also emerged as one
viable method of growing the healthcare sector while keeping public goals in mind.
The main objectives of public-private partnerships are to improve quality,
accessibility, availability, acceptability, and efficiency of healthcare services.
While different states in India have had different levels of success with
implementation of such initiatives, it is expected that the private sector will
continue to take on an increasing role in India’s healthcare system (shirin Bagg,
January 2009).
Despite the growing sophistication of the private for-profit sector, the quality of
care is rarely guaranteed, especially when the private sector has a monopoly over a
particular health market. In India where the bulk of health care providers are
private, particular concern about the quality and standards of hygiene of private
provisions in one state exists. There is also considerable over- prescribing of drugs
in several large states (Kasturi Sen And Meri Koivusalo 1998).
The need for public-private partnerships arose against the backdrop of
inadequacies on the part of the public sector to provide public good on their own,
in an efficient and effective manner, owing to lack of resources and management
issues (Sania Nishtar 2004).
Engaging in a PPP process will require governments to define clear legal and
policy frameworks and to make certain that the appropriate capacity exists within
the government to initiate and manage PPPs.
23
It is during the last two decades that the concept of PPPS has been introduced in to
the health systems. The distinction between the partnerships of 1990s and the
forms of collaboration is that the former conceptualizes both partners as equal and
is arbitrated through a formal memorandum of understanding (MOU) while in the
latter role of the non-state players was peripheral to the programme. During mid
1980s India has received the fund from the World Bank and introduced the
partnerships into the programmes like reproductive and child health programmes
[(Larbi:1999) Rama V Baru, Madhurima Nundy 2008]. The World Bank provided
the rationale and guidelines to initiate the partnerships for the developing
countries.
In India the PPPS initiated through the National Health Programmes (NHPs) and
various forms of PPPs are adapted across the regions of India. The most common
type of PPPs adapted in India are contracting in and contracting out, now a day’s
other types of the models are coming into practice ex. Social Franchising, Voucher
Schemes, Joint ventures.
The Nellis argues that “Based on empirical evidence, private enterprises often
outperform public enterprises. The World Bank found that rates of return on equity
invested in public industrial enterprises are about one-third of those in a country’s
industrial private sector” (A. Venkat Raman and Bjorkmen 2009).
The World Bank is funding the different state governments under health system
strengthening projects across the country. This project encourage the public private
partnerships insists the governments to contract out the clinical and non clinical
services to the private providers (both for profit and non-for-profit). The primary
care is services are given to non-profit-providers in many states where as
24
secondary and tertiary care service delivery handed over to the private for-profit
organisations.
In India the importance has been given to private sectors since the implementation
of the first explicit health policy in 1983. National Health Policy-1983 for the first
time proposed to expand health care provision through the private sector. National
Health Policy-2002 also envisaged the participation of the private sector in
primary, secondary and tertiary care and recommended suitable legislation for
regulating
minimum
infrastructure
and
quality
standards
in
clinical
establishments/medical institutions. Under the Tenth Five Year Plan (2002-2007),
initiatives have been taken to define the role of the government, private and
voluntary organisations in meeting the growing needs for health care services
including RCH and other national health programmes. National Rural Health
Mission (NRHM 2005-2012) also proposes to support the development and
effective implementation of regulating mechanism for the private health sector to
ensure equity, transparency and accountability in achieving the public health goals.
25
PPP in Karnataka
The state Karnataka is best known for its software industry. Biotechnology is
gradually emerging as a new area. Its capital, Bangalore, also called the Electronics
city is one of the fastest growing cities in Asia and is home to industries like
aircraft-building, telecommunication, aeronautics and machine manufacture.
The state Karnataka following the national pattern of three-tier centres and sub
centre system for providing the health services to the population. Karnataka has
developed an extensive network of health services. It also has a large number of
NGOs/ voluntary organisations involved in service delivery, community health and
development, provision of health infrastructure through the primary health centres,
health units, community health training, research, advocacy and networking.
The projects currently underway include, India Population project VIII (IPP-VIII),
India Population project IX (IPP-IX), Karnataka Health System Development
Project (KHSDP), Organisation of Petroleum Exporting Countries Fund for
International Development (OPEC), Kreditanstalt fur Wiederaufbau (KfW),
Reproductive & Child Health (RCH), Revised National Tuberculosis Control
Programme (RNTCP), National AIDS Control Programme (NACP), National
Leprosy Elimination Programme (NLEP), National Programme for control of
blindness (DANPCB) now NPCB - K, which are implemented through the
Government and Directorate of Health and Family Welfare Services(Narayan Ravi
2001).
26
Table 1.3: Health Infrastructure Karnataka
Infrastructure
Sub Centre
PHCs
Rural Population covered
4275
20760
Average No. Of Villages 3
Covered
National norms for population Plain
coverage
5000
Source: KOHFW website
16
Hilly and
tribal region
3000
Hilly and
tribal region
20000
Plain
30000
The above data shows that the infrastructure in Karnataka is above the national
norms. The Sub centres and Primary health centres covering the population above
the national norms.
Table 1.4: Health Indicators
Indicators
Rural
Urban
Combined
Birth rate (SRS 2007)
21.2
17.5
19.9
8.3
Death rate (SRS
2007)___________
52
Infant Mortality rate
(SRS)___________
Maternal Mortality
rate
Source: Kohfw website
5.4
7.3
35
47
228
The Life expectancy at birth (years) 2001 to 2006- Males 62.43 and Females
66.44
The performance of the Karnataka health system is not much significant compared
to neighbouring states. The infant mortality rate is 48 and maternal mortality rate
228 which is very high. The existing infrastructure in the Karnataka is above the
national norms, and compared to other states the infrastructure level is good. But
27
still the performance in terms of health indicators is very low. The lacuna in
delivery of the health services and organisation and management of the health
organisations is drastically affecting the outcome.
The disparity can be seen in urban and rural performance, the infant mortality is 52
in rural area and it is 35 in urban. The birth rate and death rates also very high in
rural areas compared to urban areas.
Public-Private Partnership Initiation
The public-private partnerships are initiated in Karnataka to improve the
efficiency, quality, affordability and accessibility of the services with a view to
enable optimization of resources such as human power, hospital buildings, and
medical equipment amongst others.
The temperament of public private partnerships include contracting out of non-
clinical services, management of bio-medical waste, supply of diet to hospitals,
outsourcing of clinical services to private institutions, handing over of OPEC
hospital to Apollo hospital, involvement of NGOs in leprosy work and hiring
services of private anaesthetists in face of their acute shortage within the
government.
Some PHCs are handed over to some NGOs and medical colleges to improve the
services delivery. In this scheme the private medical colleges and NGOs are
chosen according to some criteria which are fulfilling certain conditions and trusts
sponsored by reputed corporate bodies with proven managerial capacities.
In terms of management of the partnership, the Medical College / NGO / Trust is
fully responsible for providing all personnel. It is stipulated that all the personnel
employed at the least would meet the standard staffing pattern. The medical
28
college / NGO / trust is also responsible for fixing the remuneration of its
employees. The amount that is charged to patients for diagnosis, treatment, drugs
or for any other purpose has to be in accordance with the government policy.
Further, these partners are responsible for the implementation of all, National and
State Health and Family Welfare programmes (Narayan Ravi 2001).
The existing assets of the PHCs are handed over to the partner agency; who is also
responsible for the maintenance of assets with the stipulation that at the end of the
partnership, the same would be returned to the government in a proper condition.
The partner is free to make any additions to fixed assets and is responsible for
ensuring adequate stocks of all essential drugs. Financial support from the
government in the form of reimbursement of remuneration 100 percent (MOU) of
salary is payable to the government staff. Reimbursement of water and electricity
charges is subject to a maximum of Rs. 1,500 per month while Rs.25,000 per
annum is paid towards contingencies and maintenance of buildings. The budget for
drugs is based on the scale determined by the government. The funds are released
as grant-in-aid once in a quarter. The District Health & Family Welfare Officer
undertakes the monitoring of the working of the PHC. The PHC is entrusted to the
partner for a period of five years subject to review and confirmation. The
government retains powers to give directions to the agency, in public interest and
may terminate the contract for violation of conditions of contract by the agency,
after due enquiry into such violations (Narayan Ravi 2001).
29
Organisational Profile
The Karuna Trust is one of the oldest non-profit, NGO established in the year of
1986 under the leadership of Dr. H Sudarshan. Initially the KT was serving the
tribal population living in BR Hills belongs to Yelandur taluk, southern Karnataka.
The KT had its origin in the work and experience of Vivekananda Girijana
Kalyana Kendra (VGKK), which was aimed at providing primary health care.
During 1980s the Yelandur Taluk was hyper endemic to leprosy with the
prevalence of 21.4/1000 population. The KT was established to serve the
population suffering from this communicable disease.
Vision
A society in which we strive to provide an equitable and integrated model of health
care, education and livelihoods by empowering marginalized people to be self
reliant.
Mission
To develop a dedicated service minded team that enables holistic development of
marginalized people, through innovative, replicable models, with a passion for
excellence.
The primary objectives of Karuna Trust are to:
• Provide integrated development to the poor and marginalized people (tribal,
rural and urban) through health, education and training for livelihoods
• Organise and empower rural people to work towards a self-reliant
community
• Work through public private partnerships for innovative, replicable and
sustainable models
30
• Support and complement government initiatives in health and education to
improve the quality of services and encourage community participation
• Create innovative models for replication and provide benchmarks to
influence government policy and reforms
Figure 1.2: organisational structure Kanina Trust
^General Bcdy(25) Trustee^
_______v
^Executiwcommittee (9)J
I HonSftcretaiV J
Director (Scaling Upj
I
I
I PPPHeailh
| HSysoffl Branch 1
I
| JdnlOltwtorj
I
Miuiagw
Preset*
Director (HR&FInance)j Director
1
X I
I
Admin
nT*6* I**6
I
Chamr^anagaf,j
AssttMrector
| MMwgar
I
T
I
|f^ap«waM2|
I
i
IPHC SMf]
PHC
T
Mmuhu*
Manager
Coordinator
Supervisor
I__
CAPART
XT TH? Preset
FMd staff
The Karuna Trust is presently managing nearly 50 PHCs all over India. The KT
has several branches all over Karnataka and in India also. The head office is
located in Bangalore which is main responsible for management of these PHCs.
The Board of trustees consists of 25 members and executive committee consists of
9 members. The Honourable secretary is mainly responsible for the planning and
31
implementation of the programmes with the other staffs. The PPP is managed by
separate personnel. The PHC coordinators report to the joint director and joint
director reports to Honourable secretary.
This PPP initiative of Karuna Trust has grown, and in response to invitations from
other state governments, the Trust currently manages Community Health Clinic
and PHCs in Karnataka, Andhra Pradesh, Orissa, Arunachal Pradesh, Manipur and
Meghalaya in partnership with the respective state governments.
32
Conceptual framework
To improve the operational efficiency in the service delivery of the primary health
care the government of Karnataka contracted out PHCs for medical colleges and
NGOs. So in this regard the Department of the health and family welfare and
Karuna Trust came into partnership under PPP policy. Nearly 30 PHCs are handed
over to Karuna Trust in different districts of Karnataka.
This study tries to understand the process of initiation, implementation and its
functioning. So it involves key-stakeholders at different levels. To understand the
process of initiation perspectives of key-stakeholders and providers collected. To
understand the existing functioning of the PPP opinions from providers, Key
stakeholders and beneficiaries collected. The quality of service delivery is analysed
through the opinions of the beneficiaries and structural indicators.
Figure 2.1: Conceptual framework
Karuna Trust,
Karnataka
DOHFW,
Karnataka
s%arnataka PPP ppKcy
Contract c ut of PHCs
Beneficiaries’
perspective
Providers’
perspective
33
Research questions
► What are the factors responsible for the initiation of the PPP model?
► How the implementation of the programme done?
► What are the perspectives about the current implementation of the PPP
model?
►
How has the situation changed before and after implementation of the PPP
model?
► Is the PPP model sustainable?
Objectives
1. To analyze the process of initiation of the PPP model.
2. To understand the functioning of the PPP model, perspectives of the
providers and beneficiaries about the existing implementation
3. To compare the situation before and after implementation of PPP model
4. To assess the sustainability of PPP model
Stakeholders Involved In the Study
Various stakeholders who are directly involved in the programme were included in
the study.
All the Key stakeholders from the Kanina Trust are involved. The government
Key-stakeholders includes the Joint director planning, DHOs, THOs, Programme
Officers, RCH officers are included for the purpose of this study.
34
The providers included are Medical officers, Staff nurses, LHVs, Health
inspectors, and Administrators are included for the purpose of the study.
The important key-stakeholders beneficiaries who are availing the services in the
PHC are involved in the study.
35
Research Methodology
Background
The study is conducted in two PHCs which are contracted out to Karuna Trust. The
first PHC is located in Pattanayakanahalli, which belongs to Sira taluk, Tumkur
district. The PHC is located in interior and is nearly 20 Km away from the city.
The second PHC is located in Kallusadarahalli, which belongs to Arasikere Taluk,
Hassan District. The PHC is located nearly 25 km away from the city.
The PHCs are selected based upon the population covered and the year the PHCs
are contracted out. Both the PHCs are handed over to the Karuna trust because of
the previous poor performance and non accessibility.
Sampling
The study is conducted in two PHCs which are adapted by the Karuna Trust. The
PHCs are located in Pattanayakana Halli, Shira Taluk, Tumkur District and another
PHC located in Kallusadara halli, Arasikere taluk, Hassan district. The PHCs are
selected based on the population covered and geographical location.
The sample is divided into three parts they are Key stake Holders, Providers and
Beneficiaries. The in-depth Interview is conducted for seven Key stake holders
including both NGO and government. Semi-structured interviews are conducted
for providers the sample size is of nine, the inclusion criterion was the people
working in the project for more than six months and all of them qualified for that.
36
The beneficiaries were chosen randomly and semi-structured interviews were
conducted. One Hundred patients were included for this study. The inclusion
criterion was those attending the PHC for more than one six month.
The Purposive Sampling is used for the data collection. The key stakeholders are
selected, who are directly involved in the implementation of the PPP and who are
responsible for monitoring and evaluation and managing these PHCs. The
providers are selected on the basis that who are working in the project for more
than six months. The beneficiaries are selected on the basis of obtaining the
services provided by the PHC for more than six months.
Data Collection
Primary data collection
The primary data is collected using 3 separate interview schedules for key
stakeholders, providers, and beneficiaries. Interview schedule used for key
stakeholders is in-depth interview i.e. open ended questions. The interview
schedules used for beneficiaries and providers are semi-structured interview
consists of both open-ended and closed-ended questions. Different interview
schedules are used for beneficiaries and providers.
Secondary data collection
Secondary data collected through documents i.e. annual reports of Karuna Trust,
Memorandum of understanding, and monthly progress reports submitted by the
PHCs to concerned district offices.
37
Data Collection Procedure
The primary data collected from the beneficiaries in two PHCs mentioned earlier.
The sample size is equally divided for both the PHCs i.e. Fifty from each PHCs.
The exist-interview conducted for the beneficiaries when they came to avail the
services in the PHC. The duration of each interview was about 10-15 minutes per
interview.
The primary data also collected through focus group discussions. Two focus group
discussions conducted one in each PHC. The focus group discussion consists of 7-
8 members which was last for 20-30 minutes.
The providers are interviewed in both the PHCs. The interview schedule consists
of semi-structured interview. The interview last for 10-15 minutes. All the
beneficiaries who are working in the PHC more than 6 months are interviewed
during their free time.
The primary data of key-stakeholders collected in their offices with prior
appointment. The key-stakeholders from both government and NGO are
interviewed during office hours. The government key-stakeholders from both the
districts where PHCs are located are interviewed. The interview last for 15-20
minutes.
The primary data of beneficiaries and providers is collected in the month of April-
June in 2010. And primary data of key-stakeholders collected during June-August.
38
Data collection tool
The data collection tools includes
1. Providers- semi-structured interview schedule
2. Key-stakeholders- in-depth interviews
3. Beneficiaries- Semi-structured interview schedule and FGD guide
And also observation checklist used to assess the structural indicators.
Limitations
The limitations include non-inclusion of the high level government stakeholders.
The duration of the interview was not enough to collect the comprehensive data.
Some Key-stakeholders couldn’t able to answer the questions due to their time
constraints. Some lower level important government officials were not aware of
the PPP so it was a big challenge to collect the data. Probably the exist-interviews
are having their own bias. Pre-partnership secondary data of the PHC were not
available.
Data analysis:
The quantitative data from the pre-coded interview schedule was analysed using
SPSS 15 to generate frequency distribution tables. The qualitative data was read
and themes emerging from the data were noted down. Both the quantitative and the
qualitative data were then used as the basis for the analysis, findings, conclusion
and recommendations.
39
Analysis and Discussion
Initiation of the Public-private partnership
Motives for initiation
Karuna Trust was established in the year of 1996. It was the first non
governmental organisation to adapt the primary health centres under public-private
partnership in Karnataka. It was working in BR hills situated in Yalandur taluk.
Leprosy was the major burden of the disease in that area with a prevalence of
21.4/10000 population in 1986.
The government health system failed to provide effective primary health care in
that underdeveloped area due to lack of resources and accessibility. After years of
experience gained working in that region Dr. H Sudarshan took initiative to
provide the essential primary health care. To prevent the duplication of the work
and wastage of resources and improve the service delivery he took initiation to take
over the PHC. He approached the government to hand over primary health centre.
The government of Karnataka has initiated several processes to create a facilitative
environment and bring about a balanced growth of the health sector. The health
sector reform took place in Karnataka in 1990s; the PHC is handed over to the KT
under the IPP9 policy (Indian population project). The KT started providing the
care in their building due to non-availability of the government infrastructure in
Gumballi.
Dr. H Sudarshan says “NGO is not alone responsible, we don’t believe in private
health system, so to improve the health status of the people we came into PPP.”
Later the KT took over nearly 29 PHCs in Karnataka most of them are located in
‘C’ category districts where there is no accessibility and where government cannot
40
able to provide effective service delivery. The PHCs are handed over to KT
according to the “scheme for involving all medical colleges(govt/private) and other
Agencies in the Management of PHCs”.
The Pattanayakanahalli and Kallusadarahalli are located in Sira Taluk, Tumkur
district and Arasikere Taluk, Hassan district respectively. The Pattanayakanahalli
PHC is handed over on 04.07.2005 and Kallusadarahalli PHC is handed over on
10.01.2006 to the KT for complete management.
Description of partnership
The partnership between the Karuna Trust and GOK is contracting out model. The
assets of PHCs are handed over to the KT including infrastructure, equipment etc.
The option was given to NGO to posts its own staff at the PHC and in some cases
to retain the government staffs. The government staffs were withdrawn by the
government and deployed in other vacant positions.
The government has provided with the infrastructure and finance, management and
service delivery is the responsibility of the partner.
The PHCs are selected according to criteria given in “scheme for involving all
Medical colleges (Govt/Private) and others agencies in the management of PHCs”,
the criteria are as below
• PHCs which are low in performance i.e. having high MMR and low
coverage on immunisation or low institutional deliveries.
• PHCs with more number of vacancies for long duration.
• ‘C’ category PHCs which are more than 15kms. away from highways.
41
The initial contract was for two years with clause of renewal every year based on
review of performance.
Process of creating partnership
Process of creating partnership includes
• Eligibility criteria for selection of NGO.
• Legislation or policies made before the PPP
• Community need assessment before hand over PHC
• Clarity of purpose
• Participatory approach
• Selection of the NGO
Selection of the partner to hand over the PHC is a vital for sustainability of the
programme. The eligibility criteria were drawn under the scheme for the selection
of the NGOs.
• The NGO should be working in rural areas with legal status of a society
registered for three years under the Societies Registration Act or any
corresponding State Act or as a Trust registered under the Indian Trust Act,
1882 or the Charitable and Religious Trusts Act, 1920.
• The NGO Should be active and its financial position should be sound. This
should be evident from the audited statements of accounts for the past three
years.
• The NGO should be a reputed one with demonstrated capacity and dedicated
management body.
• The NGO should not have been a defaulter in respect of any funds received
from any of the Government Departments.
42
Figure 4.1: Process of creating partnership
Proposal submission
NGO
Scrutinised by DHS with
> reference eligibility criteria
Commissioner of Health &
Family welfare services
Selection committee will take
decision
Directorate of health and
family welfare
The non-governmental organisation send proposal to commissioner of health and
family welfare services to adapt PHC. The district health society scrutinised the
eligibility criteria of the NGO and it has submitted report to the selection
committee which consists of eleven members. The selection committee decided to
hand over the PHCs. The directorate of health family welfare, Karnataka
communicated with the NGO and begun the implementation of programme.
The clarity of purpose and commitment is necessary. The Memorandum of
understanding drawn clearly shows the clarity of purpose and commitment.
43
Bringing two partners together is a challenging as well as long term process. Dr.
Sudarshan says “process of creating partnership is a long process. The challenges
we faced are mistrust from both the sides initially. Government was looking
towards the NGO is incapable of managing the PHC and also they were suspecting
about corruption.”
During the initial implementation of the PPP there was resistance from the
villagers. There were mobs opposed the PPP, because they thought it is
privatization of the service delivery. So the people from NGO and government
went to field and made them understand what public-private partnership means and
took their consent to implement the project.
Design of the contract
Staffing pattern
The Karuna Trust took full responsibility to recruit personnel at the PHC and the
sub-centres coming within its jurisdiction. Most of the staff of the government
were withdrawn from the PHC by the government and re-deployed in other
required PHCs. Some personnel were retained on deputation basis by mutual
consent of the agency. The staffs are appointed accordance with the staffing norms
of the department in the PHC/ sub-centre. At least minimum qualification is
prescribed while recruiting the personnel for PHCs and Sub-centres.
The NGO fixed the remuneration of its employees but it is not less than fixed by
the government. The salaries of the deputed personnel from the government are
governed by the terms of deputation. The minimum staffing pattern was prescribed
by the government for PHC i.e. Medical officer, staff nurse, Lab technician, LHV
etc to ensure the quality of services.
44
Services to be provided
There is a clear cut demarcation of the purpose of PPP and clarity on objectives to
be achieved. The KT is responsible for providing the primary health care that is
implementing all the national and state health programmes. The sole responsibility
of the KT is to improve the service delivery and create demand for the services and
increase the community participation. Especially the PHCs in the northern part of
Karnataka which are notified as less institutional deliveries are handed over to the
KT. The programme is designed such that no patient is charged for any services in
the PHC i.e. diagnosis, treatment and drugs.
The government provided the existing assets of PHCs and sub-centres i.e.
infrastructure, equipment and some personnel to the KT for the duration of the
entrustment. All these assets are maintained by the KT and will be handed over
back to the government after the period of agreement.
Period of entrustment and financing mechanism
The PHCs are handed over to the KT for initial period of two years subject to
review and confirmation of the arrangement after one year and later extended to
five years. Each intervention will be evaluated in fifth year on the basis of the
experience of the past four years. The performance of the PHCs will be evaluated
by an external agency and the renewal entrustment will be considered (Arogya
Bandhu-appendixII).
To reduce the burden over the NGOs the government of Karnataka has increased
the earlier 75% reimbursement of the actual remuneration to 100% in respect of the
staff employed by the agency subject to a maximum of the midpoint of the pay
scale in the government. The remuneration paid to staff in excess of the staffing
pattern norms of the department is met by the KT.
45
Along with the reimbursement of salaries the government of Karnataka according
to Arogya Bandhu scheme also provides the POL charges with a ceiling of 100
litres per month to maintain the ambulance and any other exclusive vehicles. The
phone, water and electricity charges are also reimbursed subject to maximum of
Rs. 1500/- per month. Every year the budget for drugs is determined by the
government of Karnataka presently it is paying one lakh rupees per annum.
The NRHM funds from the central government or state government provided to
the PHCs maintained by the KT similar to that of government PHCs. This is
managed by the THO in consultation with the managing NGO/administrative
doctor. The fund to the KT is released by the District Health & Family Welfare
Officer out of the District/State sector budget.
Monitoring of the PHC
There is no separate team or department for monitoring of the PHCs taken by the
KT. All the PHCs taken by KT are monitored by District Health Officers, Taluk
Health Officers and Programme Management Officers similar to that of
government PHCs with reference to the services rendered by the PHC under the
National and State Health & Family Welfare Programmes and provisions of
general health care services in the PHC as per the general directions of the
Government.
Process quality indicators are given to measure the outcomes of the partnership
agreement (appendix II).
46
Participatory approach
Success of any community level programme depends on the participation of the
people of that community. Greater the support obtained greater will be the outcome
of the programme, so making the beneficiaries to understand partnership and gain
willingness of the community to accept the public-private partnership is crucial
aspect before taking over the primary health centre. The process of initiation
includes creating awareness in the community through publicity, meetings and
consultation where it going to serve. The involvement of the local people in
decision making will increase the confidence about the partnership and also it will
enhance the number of people availing the facility. The poor performing primary
health centre is handed over to the non-govemment organisation. The perspectives
of the people of the community about the PHC before the partnership due to low
quality of care provided de-motivate them to avail the facility. So the initial
publicity and consultation regarding the partnership and its benefits will reduce the
resistance and will allow easy implementation of the programme with support of
the community. The feeling of belongingness will leads to increased service
utilisation with better outcome results in sustainability of the partnership.
The study conducted in two PHCs
1.
Pattanayakanahalli-PHC, Shira taluk, Tumkur district.
2.
Kallusadarahalli-PHC, Arasikere taluk, Hassan district.
The study trying to reveal how many people are aware of the programme, how they
come to know about it? Is meeting or consultation done before the beginning of the
programme?
47
Pattanayakanahalli PHC
Figure 4.2: Awareness about PPP
90% -|
80% 70% -
60% 50% 40% 30% 20% -
10% -
0% -
I
yes
no
Out of fifty beneficiaries interviewed in Pattanayakanahalli PHC, 82% says they
are aware of the public-private partnership and rest 8% is not aware of the PPP
even though they are availing facility since so many years.
Table 4.1: How beneficiaries come to know about PPP
Source of information
Hoardings______
Initial strikes
Neighbours_____
Family members
Meeting_______
Not aware of PPP
Percent
age
48.0
12.0
6.0
2.0
14.0
18.0
Total
Frequen
cy_____
24
6
3
1
7
9
50
Out of fifty people interviewed in Pattanayakanahalli maximum percent of people
(48%) came to know about PPP seeing hoardings (billboard) outside the PHC after
visited for treatment. There were some conflicts in the beginning regarding
handing over the PHC to Karuna Trust, people misinterpret it has complete
privatization which made them to oppose the implementation. There were strikes
against the KT and government, through these strikes 12% of the people came to
48
know about the programme. Hardly 14% of the people say they got to know about
the PPP meeting conducted before the initiation of the programme. Eighteen
percent of fifty beneficiaries were not aware of the public-private partnership
programme implemented in Pattanayakanahalli.
Kallusadarahalli
Figure 4.3: Awareness about the PPP
100% ->
90% 80% 70% 60% 50% 40% 30% 20% 10% 0% -
I
yes
no
Fifty beneficiaries are interviewed in Kallusadarahalli PHC. Nearly 94% of the
people availing the facility are aware of the programme and remaining 6% are not
having any idea about the maintenance of PHC by KT.
Table 4.2: How beneficiaries come to know about PPP
Source of information
Hoardings______
Initial strikes
Neighbours_____
Family members
Meeting_______
Not aware of PPP
Percent
age
62.0
10.0
6.0
4.0
12.0
6.0
Total
Frequen
cy_____
31
5
3
2
6
3
50
49
Sixty two percent of the beneficiaries came to know about the PHC management
by Karuna Trust only after seeing the billboard outside the PHC. And 10% of
interviewed beneficiaries out fifty said they got to know about it during initial
strike against handing over the PHC to KT. And hardly 12% agrees that meeting
conducted before initiation and they got to know about the programme.
Analysis of functioning of the PPP model
The functioning of the PPP model depends on various factors. The PPP is to
facilitate effective service delivery at PHCs where government cannot able to
manage. The health is a state subject, so governments are searching for ways to
improve equity, efficiency, effectiveness and responsiveness of their health
systems. The effective functioning of the Primary health centre is not only the sole
responsibility of the NGO which is maintaining the PHC. It depends on the
partnership how effectively it is designed and executed.
Functioning of public-private partnerships is analysed with the help of following
elements.
1. Exchange of information/communication between the partners
2. Shared goals and trust between the partners
3. Shared decision-making and management responsibility
4. Managerial independence and autonomy given to partner
5. Governance structure to oversee implementation, monitoring and evaluation
6. Joint planning and activities
7. Benefits and risk shared between the partners
8. Accountability and Financial Flow
9. Performance indicators (structural indicators and outcome indicators)
50
10. Patients satisfaction of quality of service provided
Although these characteristics are shared, the goals, structure, and organisation of
partnerships vary widely. For example, the types and amounts of resources
contributed by the partners will differ according to ability. Similarly, the extent of
shared decision making will depend on the resources and constraints of the various
partners, such as technical expertise, fundraising capability, potential conflicts of
interest, legal responsibility for the oversight of public funds, and other
considerations.
Exchange of information/communication between the partners
For any contract arrangement to succeed, it is essential to have performance
indicators that get monitored periodically. Bennett and Mills describe the
requirement for an information system that will assist in decision-making on
awarding contracts and the supervision thereof. While health ministries keep
records on epidemiological and administrative information, very few countries
have created the formats and records needed to monitor NGO contract compliance
(A. venkat raman & Bjorkmen 2009).
Factors that hinder partnerships at the operational level are lack of communication
between partners to discuss problems and solutions, lack of regular meetings,
incomplete exchange of information or reluctance to share information, and lack of
consultation about quality and service standards. Other problematic factors include
frequent turnover of key personnel, lack of authority by field managers to take
decisions, authoritarian or overbearing supervision, lack of awareness about
51
partnerships by lower-level officials and prejudices or misconceptions about the
motives of partners or their so-called hidden agenda.
The Karuna Trust to improve the health information system implemented the
‘health management information system’ in all the PHCs. The monthly report is
submitted to the concerned Taluk and district office.
Dr. Sudarshan says “there is regular exchange of information between the NGO
and government during the implementation of project. Now, the relationship
between the partners is good.”
The District Health officer, Hassan says “the relationship with the NGO at the
beginning was good, but now there is a gap exists and communication is not good
due low performance of the PHC.”
The programme officer of the Hassan district complaining about the
Kallusadarahalli PHC regarding the delayed submission of the monthly reports and
also some time they received wrong reports and they came to know about this after
the field visit.
The programme officers of Tumkur district appreciating the performance of
Pattanayakanahalli PHC and the discipline and timely report submitting.
Shared goals and trust between the partners
Ideally relationships are built on trust and on understanding of mutual objectives
but these evolve over long periods of time.
Trust is one of the most critical issues for the success of a partnership. There is
contractual trust (expectations that partners will keep their promises) and ‘goodwill
52
trust’ (mutual expectations of open commitment to each other). While both imply
the absence of opportunistic behaviour, ‘goodwill trust’ is particular to relational
contracts as opposed to classical contracts. A third type of trust - ‘competence
trust’ - refers to expectations that one party will competently carry out tasks whose
technicalities are beyond the capabilities of the other party (Allen 2002). Whatever
the degree of trust, partnerships must be guided by clear terms and conditions,
defined structures and performance indicators.
Adherence by each partner to mutual obligations and commitments is critical in
any partnership. Failure to fulfil mutual responsibilities leads to disaffection,
conflict and lack of trust among the partners and among other stakeholders.
Dr. Sudarshan says “The shared goals and trust between the partners are continued
even now, the partnership enhanced the public image of both the NGO and the
government.
But the government key-stakeholders of Hassan district are not well satisfied and
complaining of poor performance of the PHC and the benefits to the community
mentioned during the contract is not been provided now. So in their opinion the
shared goal and trust is no more continuing. The partnership failed to enhance the
public image for both the government and NGO.
Shared decision-making and management responsibility
Often used to describe an ideal form of partnership, collaboration involves shared
decision-making power over planning and implementation of programs. It is based
on mutual respect, acceptance of autonomy, independence and pluralism of private
opinions and positions (A. Venkat Raman and James Warner Bjorkman 2009).
\SS4-1
IS 8^
53
When hospitals or health service establishments are given financial and
administrative autonomy, it is presumed that flexibility in decision-making will
lead to more efficiency, improved quality and greater accountability.
The
decision-making
in
Policy
formulation,
Planning,
Implementation,
Monitoring, evaluation, Training & Research is equally shared between the
partners according to the KT’s perspective. The key-stakeholders from KT say the
most of the decisions are made with the consultation with the government
stakeholders and also agrees that autonomy has given by the government in
decision-making.
The shared decision-making helped KT to implement the innovations in the
primary health care. The decision-making power enabled the organisation for
effective implementation of the programme and also leaded to share the
responsibility equally.
Managerial independence and autonomy given to partner
One of the conditions for a true partnership is the relative autonomy of both
partners in day-to-day operations as well as in overall management. Autonomy is
characterized by the non-intrusiveness of the public sector partner (except its roles
of funding, oversight and monitoring) and by the freedom of the private agency to
take operational decisions without resorting to cumbersome bureaucratic
approvals. Once a partnership agreement has been signed, each partner assumes its
responsibilities without being constantly told about ‘dos and don’ts’.
The NGO as got that autonomy and independence to take decision in terms of
planning project and implementing it accordingly. It got managerial independence
54
to recruitment and terminating the health personnel etc. The organisation re
designated the post of ‘clerk’ as PHC administrator who is responsible for
management of PHC including the finance.
The KT also got considerable autonomy to incorporate additional services or to
conduct innovative experiments like using indigenous systems of medicine,
community health insurance, outreach services and round-the-clock emergency
care, mobile health clinics and human resource management.
Even though managerial independence and autonomy is given some decision are
made with consultation with the government because there is some kind of
hierarchy exist between the partner especially government dominance can be seen.
The government stakeholders are having dissimilar perspectives about the PHC
managed by the KT. The district level government health administrators trying to
dominate and imposing their ideas rather than thinking rationally, what can be
done?, it is the opinion of the key-stakeholder of the KT.
Governance structure to oversee implementation, monitoring and evaluation
The government doesn’t possess a separate structure to oversee the implementation
of the PPP model in Karnataka. The primary health centres in the particular
districts where Karuna Trust has adapted has been managed by the District health
officers, Taluk Health officers and programme officers as like other PHCs.
The monitoring and evaluation of the PHCs depends on effective governance in the
districts. Out of two PHCs investigated the M & E done regularly in one PHC
(Pattanayakanahalli). Most of the PHCs adapted by the KT are computerised and
Health management information system implemented. The monthly report is
submitted to the district health office.
55
From the NGO side the performance is monitored by the administrative
department. The PHC co-ordinators are monitoring the performance and the
personnel from the head office visit all the PHCs regularly. The auditing will be
done on regular basis every monthly by KT.
The performance of the PHC also depends on how monitoring and evaluation done
from the government side. The detailed investigation shows that the performance
of PHC was good where there is government administrators visit PHCs regularly.
The PPP always increase the responsibility of the government because it is having
hidden risks.
Joint planning of activities
The success of the programmes in the PPP is successful when it is planned jointly
by the partners. The joint planning of activities will increase the trust between the
partners as well as it will increase the responsibility of both the partners. The belief
of the government stakeholders at the district level is that only the partners are
frilly responsible for the planning and implementation of the programme. The
perspective of the stakeholders about PPP has to be changed and should realise that
the PPP includes the joint planning of activities. The government is ultimately
responsible for the delivery of services so the private sector is seen as an agent of
the government. Only in some districts where officials are aware about the PPP
involve the PHCs adapted by the partner involve in planning and decision making.
Dr. H. Sudarshan Says “Primary health care is the responsibility of the state. PPPs
[public-private partnerships] are not alternatives to poor governance and
leadership. Even with the PHCs we manage there are variable degrees of progress.
In districts where the District Health Officer understands the rationale of the PPP
and provides constructive leadership, the progress has been tremendous. In others,
56
progress has been slow. PPPs can work only with the support of strong, honest, and
able governance.” (Bharathi Ghanhashyam 2008)
Benefits and risk shared between the partners
The success of the partnership depends on the benefits and risk shared between the
partners. In case of for-profit partners the benefit is in monetary terms and rate of
return on investment but it is different in the perspective of the non-for profit
agencies. Non-profit partners gauge their benefits in terms of community service,
financial sustenance, community support and altruistic satisfaction (A. Venkat
raman and Bjorkmen 2009).
In case of Karuna Trust because it is a non-for profit organisation the benefits are
in terms of providing the service to the community, sustainability, community
support and altruistic satisfaction. The partnership increased the image of the KT
after partnership and it helped the organisation to achieve the objectives. The
reputation got through PPP helped the organisation to get the financial leverages
from various funding agencies. The increase in financial flow enhanced the
organisation to scale up their community service and enabled the organisation to
adapt the PHCs in Karnataka as well as in other states also. The funding from
various agencies helped the organisation to provide some of the innovative services
in the primary health care. The KT providing the mental health services, traditional
medicine and implemented the community insurance schemes.
At the same time the image of the public partner gone up due to increased quality
of service in the PHCs where the performance is well. There increase in the
number of patients who are availing the facility in the government health system.
The PPP enabled the government to implement the national health programmes
effectively.
57
Along with the benefit there is risk involved in the public-private partnership. In
the non-profit agencies financial and reputational risk are very high. The NGO can
perform well if it is financial sustainable, but most of the NGOs are purely depends
on the external funding. The KT is also not exceptional from these financial
complications. The fund is flowing from the various funding agencies for the
management of the PHCs and from the government. If the grant is not released in
time it will affect the services provided in the PHC results poor service delivery.
The public image of the PHC is depends on the quality of service provided. The
public image has gone down in one the PHC investigated (Kallusadarahalli PHC).
The poor management of the PHC the quality of service provided was awful. So
people protested and complained against the PPP.
Accountability and Financial Flow
Accountability can be defined as holding the providers of services answerable to
the beneficiaries and other stakeholders regarding both process and outcome of a
programme. Transparency, participatory planning and decision-making, and
evaluation are necessary conditions for accountability.
“Each PHC serves nearly 30,000 people. If the quality of service provided is low
people will complain to higher authorities. So people themselves held the
responsibility and they question us, we are answerable to their complaints. As well
as each PHC consists of Arogya Raksha Samiti consists of various stakeholders
including the community representatives, so the transparency is well assured” says
Dr. H Sudarshan.
The timely reports are submitted to the government office as well as to the KT
office. This will provide with complete details of process and outcome of a
programme. The government officials can cross check through regular visits.
58
Monthly financial auditing is in place for the funds released by the KT and
government. The PHC administrators are responsible for submitting the financial
expenditure of each month. But KT is not looking after the funds released for
NRHM especially for JSY and untied funds.
But in the view of some government stakeholders ‘accountability is not ensured
from the community side. People are not aware of facilities provided and they
don’t question the type of service provided, quality of service and the facilities
available. The community should be empowered and should ensure active
participation of the community people in the programme. This will ensure more
transparency and accountability. The ARS committees in some PHC are not
functioning properly. The members from the community side not aware of the
facilities available and the guidelines regarding utilisation of the funds released.
They agrees even in the PHCs which are taken by the KT same scenario exists.
It is the fact the PPP is not the alternative to poor governance. The perspectives of
the government stakeholders show that the maintenance of the PHC is complete
responsibility of the partner which is detrimental to growth of the PHC. The
community people complain about existence of corruption to some extent, The
lower level officials have to be trained regarding the administration and
management of PHCs adapted by private agencies.
Finance
The primary health care is the basic need of the people so, at any cost people
should not be charged with user fees. The primary health care is provided at free of
cost is completely funded by the government because health is state subject.
59
The government purchased the service from the Karuna Trust. The government
reimburse 100% salaries and some other financial assistance to the KT. For
management and administration it depends on the donors.
The payment system is retrospective; all the payment will be done only after
submitting the required bills from the NGO. There is delay in the release of funds
to the KT from the government. Finance manager Mr. Manjunath says “there is
backlog of nearly 18 lakh from the government, so the salary was not given to the
employees in time.”
Some of the PHC staffs are de-motivated due to delay in the salaries. Some staffs
complaining they have not received salaries for 8-10 months. So it was very
difficult for the KT to retain its staffs. This will deteriorate the quality of service
provided.
Performance indicators (structural indicators and process indicators)
Pattanayakanahalli PHC
The PHC located in Pattanayakanahalli, Sira Taluk, Tumkur district. It is one of
the biggest PHC which is covering population of 35801, and covering the 11 sub
centres.
PHC BUILDING & STAFF QUARTERS
The building is renovated after the contract given to the KT. The building was
repainted and cleaned, name boards are displayed. The quarter for medical officer
and other staffs also renovated.
The present condition of the PHC building is good & hygiene maintained well. But
quarter for the staff is not in good condition, medical officer complains about the
ill condition of the quarter.
60
EQUIPMENTS AND FURNITURES
The PHC is provided with computer printer for the implementation of the HMIS
system and IEC activities. The village resource centre equipments were installed in
collaboration with the ISRO. But the currently the village resource centre
equipments are not working and even no staff available for maintenance of these
equipments. The telemedicine implemented successfully and initially it was
working but presently not utilised due to various problems says the PHC
administrator.
To facilitate the patient waiting and comfort furniture’s are in place. Through
various donations KT successfully purchased and facilitated with furniture for the
PHC.
STAFF
KT has filled up all the vacant posts.
Table: 4.3: Staff availability PN Halli
SI.
Post
Sanctioned Available
SI.
post
Sanctioned Available
no
no
1
Medical officer
2
2
9
Jr. H A (M)
7
7
2
Pharmacist
1
1
10
Jr.H.A (F)
11
11
3
Staff Nurse
1
1
11
PMOA
1
1
4
Lab. Technician
1
1
12
SDC
0
0
5
1
1
13
0
1
1
14
Arogyamitr
a_______
Driver
0
6
FDA/Administr
ator________
LHV
1
1
7
BHEO
1
1
15
Gr. D
3
3
8
Senior Health 1
Assistant
1
61
All the vacancies are filled up by the KT and most of the staffs are staying in the
accommodation provided. Two medical officers are deployed, one MBBS and
AYUSH doctors deployed.
MEDICINES & REGENTS
KT supplies the essential medicines & other lab reagent if there is shortage in
Govt. Supply, Free medicines were received from Micro Labs and supplied. But
sometimes there will be shortage of medicines due to irregular supply. The user
fees (2 Rs) collected will be used to purchase the medications during shortage of
medications.
Table 4.4: Statistics PN Halli
SI.
Process indicators
no
1
2
3
4
5
7
1
2
3
2005-
2006-07
2007-08
2008-09
2009-10
2010-11
38080
749
38931
751
39374
713
39630
849
39820
837
35801
662
435
58%
505
67%
471
66%
594
70%
627
74%
628
94%
784
615
371
60%
753
623
464
74%
713
604
484
80%
758
676
615
91%
442
690
646
94%
729
635
635
100%
Vital Indicators
j_
0__
0__
613
622
600
27.64
27.29
16.56
0__
672
16.37
J__
j___
630
23.80
06
Population
Total
ANC
Registration
Early
ANC
Registration : 12
weeks____
TT coverage ANC
Total Deliveries
Institution Deliveries
% of institutional
deliveries
Maternal Deaths
Total Live Births
1MR
684
17.54
There is significant increase in the process indicators over the years. The
percentage of early registration picked up from 58% in the year of 2005-06 to 94%
in 2010-11 gradually. The effective utilisation of the JSY funds reflected in the
62
gradual increase in the institutional deliveries. In the year of 2010-11 the
institutional deliveries are 100%.
Table 4.5: Quality of service provided (patient perspectives on service delivery)
Indicator
Medical officer spent
sufficient time_________
Whether he listened
properly?_____________
Whether he explained
treatment?____________
Services available at
convenient time________
Is the waiting time is long?
Whether referral done
accordingly?__________
Whether quality of service
provided increased after
PPP?
Yes
100%
Patient perspective
I No
0%
98%
2%
96%
4%
92%
8%
14%
98%
86%
2%
78%
2% (rest 20%
not aware of
PPP)
After the implementation of the PPP the quality of service provided is improved.
Initially the service provided was good and later declined due to non availability of
the MBBS doctors. After the MBBS doctor deployed they are getting services
needed they says. They agree the medical officer listening to them and give
sufficient time to treat them well. And he explains the treatment and the
medications. The medical officer and the other staff stay back in the quarter so the
services are available all the time. Due to increased patients flow there is some
waiting time 14% people says. The patients are referred to higher institutions for
advanced care properly. To ensure the quality of service provided the availability
of staff twenty four hours is important. The staffs are not found much satisfied due
to some lack of facilities.
63
Kallusadarahalli PHC
The PHC is located in the Arasikere taluk, Hassan district. It is taken by the KT in
the year of 2006. It covering population of 26912 and covering 7 sub-centres.
PHC BUILDING & STAFF QUARTERS
The newly constructed building handed over to the KT. The beneficiaries says the
PHC was well maintained in the beginning but not now. The PHC and staff quarter
needs renovation. There is problem with water facility and electricity. The
cleanliness maintained was not satisfactory.
EQUIPMENTS
The computer, printer and tape recorder provided by the KT were not in working
conditions. Due to interrupted power supply the computer to maintain the HMIS
system neglected. The staff are not enough skilful to operate the equipment
provided, it also one of the reason for non-use of the available resources.
STAFF
All the vacant posts were filled up by the KT.
Table 4.6: staff availability K. Halli
Sl.no
Post
Sactioned Available
SI.
Post
Sactioned
Availabl
e
no
1
Medical officer
1
1
9
Jr.H.A (M)
5
5
2
Pharmacist
1
1
10
Jr. H.A (F)
5
5
3
Staff nurse
0
0
11
PMOA
1
1
4
Lab. Technician
1
1
12
SDC
1
1
5
FDA/Administr
0
0
13
Arogyamitr
0
0
ator
a
64
6
LHV
1
1
14
Driver
0
0
7
BHEO
0
0
15
Gr. D
1
1
8
Sr. H.A.
0
0
The medical officer is not staying in the head quarter provided. Beneficiaries are
complaining about the non-availability of the services during night time. The
emergency and obstetric care is not available at night. The staff nurse post is not
sanctioned and available in the PHC.
MEDICINES & REGENTS
KT supplies the essential medicines and lab reagent in case of delay in Govt.
Supply, The lab reagents were also supplied from KT.
Table 4.7: Statistics K. Halli
SI.
Process indicators
2006-07
2007-08
2008-09
2009-10
2010-11
Population
ANC
Total
Registration
ANC
Early
Registration < 12
weeks____
TT coverage ANC
Total Deliveries
Institution
Deliveries_______
%
Institutional
Deliveries
24840
264
25044
327
25219
385
26486
435
27028
418
260
98%
311
95%
319
83%
375
86%
358
85%
332
213
121
331
279
137
322
267
256
388
373
365
397
421
413
57
49
97
98
98
0___
370
13.514
0__
406
4.92
no
2
3
4
5_
6
7
3
Maternal Deaths
Total Live Births
IMR
Vita Indicators
0__
_1_______ 0__
279
267
213
11.24
18.12
37.56
65
The indicators in the table also depend on the performance of the PHC. There is
gradual increase in the number of institutional deliveries over the years. There is a
decrease in the IMR from 37.56 in 2006-07 to 4.92 in 2010-1 l(May also due to
other factors). At the same time we can observe decrease in the percentage of early
ANC registration.
Table 4.8: Quality of service provided (patient perspectives on service
delivery)
Indicator
Medical officer spent
sufficient time__________
Whether he listened
properly?______________
Whether he explained
treatment?_____________
Services available at
convenient time_________
Is the waiting time is long?
Whether referral done
accordingly?___________
Whether quality of service
provided increased after
PPP?
Patient perspective
Yes
84%
I No
84%
16%
80%
20%
64%
36%
38%
84%
62%
54%
40% (rest 6%
not aware of
PPP)_________
16%
16%
(Sample size) N= 50
The KT faced lot of resistance during the implementation of the programme in
Kallusadarahalli. The quality of service provided remains unchanged even after
PPP says 40% of the beneficiaries interviewed. The KT initially failed to retain the
staff in the PHC. Compare with the Pattanayakanahalli PHC the performance and
quality of service provided is lower. Nearly 36% of beneficiaries complain about
the non-availability of the services at convenient time. Some people agree that only
because of the experienced medical officer they are availing the facility. At the
66
same time they complain that staffs are not staying the quarter, so night time if any
emergency or delivery they are depending on 108 service.
Changes before and after PPP
Pattanayakanahalli PHC
Infrastructure
After the PHC handed over to the KT it is renovated and with the help of donors
new building has been constructed. Most of the providers and beneficiaries
interviewed agrees about the changes occurred after the PHC handed over to the
KT. Previously there were no facilities for patient comfort (chairs and tables),
toilets and IEC boards were written and name boards were put in place. The
number of beds increased, new vehicles came and mobile clinic is provided to
serve the outreach population. The quarters were renovated and allocated to the
staffs. There was no fencing around the PHC when handed over, the fencing done
under the Sujala project. The earlier PHC was plagued with lack of water and KT
facilitated with the help of some donors. New equipments were provided. New
computers, printers, ECG machines, IEC materials and IEC vehicle were provided.
Human resources
Karuna Trust filled all the vacant post after handing over the PHC. It deployed two
doctors both allopathic and Ayush. It also deployed other cadre of health workers
like pharmacist, lab technician, PHC administrator, refractionist, two staff nurses,
LHV, group D workers.
The KT got the freedom to recruit the staffs and fix the salaries. The salaries
should not be less than government scale. The KT re-designated the post of first
67
division clerk to PHC administrator who is responsible for overall management of
the PHC.
New types of services provided
To provide the comprehensive care KT incorporated some new services. The
providers were trained to provide mental health care. Community insurance
implemented initially but it failed. The IEC programmes were organised in
effective manner in all the sub-centres.
The PHC administrator Mr. Jayaram says “the PPP brought lot of changes, the KT
introduced traditional medicine in most of the PHCs, and the PHC is upgraded to
24 hour service. The ANMs are strictly instructed to stay in the sub-centre and
regular monitoring done and training is given regularly. The mobile health clinic
brought lot of changes in the health of the villages in the remote places (nearly 10
villages in taluk). Mental health clinics and cataract operations started, which is the
most needed one.”
Mobile health services are provided to the outreach activities and extra vehicle is
provided with charges of rupees 200/-“. The KT is given the special training to him
in maintaining stock and Bin card system. The LHV of the PHC says “the Sneha
clinic has been introduced to provide sex education to the girl children who are in
high school every Thursday.
Village Resource centre equipments were installed in collaboration with ISRO.
Tele conference and Tele- ECG facilities are made available in the PHC. But they
are not in working condition and no staffs are provided to operate these
equipments.
68
In the opinion of the lab-technician before KT take over PHC only TB and routine
blood testing were done. After implementation of the PPP new lab reagents are
provided and the training also been provided to conduct other kinds of tests. So
now almost all kind of investigations according to PHC standards are done in this
PHC.
Kallusadarahalli PHC
Infrastructure
The newly constructed building handed over to the KT. After KT took over the
PHC, fencing around the PHC has been done. The PHC has been provided with
some new equipments and beds. But PHC lacking with some furniture’s to increase
the patient comfort during waiting time. According to opinion of the people the
present condition of PHC is not good, hygiene not maintained and renovation
done. The staff quarters should be renovated and there is need of 24 hours water
facility.
Human resources
Interview of the beneficiaries and providers reveals that there is substantial
increase in the human resource in the PHC. The KT deployed medical officer with
MDBS qualification, lab technician, pharmacist, group D workers and other
workers. But the post of staff nurse is vacant so obstetric care provided has its own
limitation. The health assistants are recruited from same community. ZP member
from that community complains “earlier no doctor was posted, PHC faced with lot
of problems with deployment of the doctor, so people of the village complained
against this. The staff nurse post is still vacant so obstetric care is not available
during night time. The doctor is not residing in the quarters”
69
New type of services provided
The Karuna Trust initially tried provide innovative services like traditional
medicine, health insurance etc, but failed to implement in proper way due to lack
of human resource and finance.
70
SUSTAINABILITY
Sustainability is very crucial for success of the partnership. It is very important to
ensure that the partnership is sustainable from financial, institutional and political
perspective in public-private partnerships. The financial sustainability plays a
major role at the same time importance given to the institutional and political
sustainability. Measuring financial and institutional sustainability is easier when
compared to political sustainability.
The partnership with non-governmental organisation may share less risk as
compared to that of private partner, but having its own constraints and limitations.
One of the main issues with the NGOs is sustainability. Some of the difficulties
they frequently face are shortage of trained staff, high turnover of middle-level
workers and dependency on donor agencies.
Berman and Dave (1994) found that not-for-profit hospitals are able to achieve
efficiencies due to low wages of employees by using contract workers, utilizing
specialist services on an honorary basis, prescribing generic drugs and emphasizing
referrals as well as limited use of expensive technology. As a result, the average
total expenditure per hospitalization in a charitable institution is less than in forprofit hospitals.
There are a number of features of NGOs that are conducive to sustainability. These
include: the perception that the quality of care that they provide is considerably
higher than that provided by the government and thus the demand for their services
is higher; non-bureaucratic and flexible style of operation, which can allow them to
more readily experiment with innovative service delivery programs and financing
mechanisms; close links with the communities they serve; and “motivational
force” in harnessing a spirit of volunteerism and service (Gilson et. al, 1997).
71
The sustainability of KT is measured using following elements.
• Financial Sustainability: Sources of income, income generating activities
of the NGO, strong financial management and control (including good cost
accounting systems), a diversity of funding sources, financial planning
capability, existence of an investment strategy, etc;
• Institutional/Management Capacity, which includes such elements as a
clear organisational structure, a strong board of directors, sound
management
practices
and well-functioning
administrative
systems
(including management information systems), and marketing skills to be
able to expand services
• Technical or Programmatic Capacity, which includes the ability and
commitment to provide high quality services, ongoing staff training and
assessment, the existence of clinical standards and other quality assurance
measures, and information, education and communication (IEC) programs.
• Community Support: The acceptance of the quality of service by
community, How community will support if partnership withdrawn.
72
Financial Sustainability
Figure 4.4: The major sources offunding for NGO
Income sources
■ government
■ funding agencies
■ General donations
■ rental income
■ user fees
■ interest on SB
4.85
%_
2.75%
l-0?%_0.50%
,90.80 ■
Source: KT annual report 2010-11
The KT receives major source of fund from the state governments (almost 91%).
And next major source of income is from the donor agencies including both
international and local donors. Rental income contributes hardly 1.02% for the
income. Negligible amount of contribution can be seen from user fees and interest
on savings.
If the government stops funding temporarily for the programme the KT doesn’t
have any other sources of income to sustain the programme. As per the statements
of the employees in the Karuna trust government has not sectioned the grants of
nearly one year (salaries). The staffs have not received the salaries since 8-9
months which will hamper the motivations.
73
If the government stops funding the organisation cannot introduce the user fees. No
other fund the PHC is receiving to continue the programme. The main mission of
the NGO is to serve the poor people who are the least able to pay.
NGOs that serve primarily the very poor are often limited in their ability to raise
funds within the communities they serve. When fees were increased at the Rxiin
Tnamet clinic, located in Santiago, Atitlan, in Guatemala, many clients stopped
going (Denise DeRoeck, March 1998).
Another conflict arises from the focus of many NGOs on providing preventive care
services, which people are often less willing to pay for than curative care. A further
set of conflicting goals involves expanding services to increase coverage versus the
desire to keep the organisation and service priorities “manageable.”
The donor agencies contribute hardly 5% of the total income. The grants received
are utilized for different programmes. The grants are utilized for administration,
and scale up the services. Even though organisation having diversity of funding
sources including revenues generated outside the donations amount is negligible
for maintenance of all PHCs.
The organisation key-stakeholders says “the health is state responsibility, the
government will not stop funding the programme, suppose if it stops funding us we
cannot introduce the user fees to the community. The ultimately there will be no
other option other than with drawing partnership.”
74
Institutional/Management Capacity
The partnerships success also depends up on the institutional capacity of the
partner. The institutional capacity can be assess through organisational structure,
management and administrative capacity marketing skill etc.
Denise DeRoeck (March 1998) argued that “since NGOs are usually founded as
social enterprises or charities, often with donor funding, they tend to lack a
business orientation, as well as strong planning and management capabilities and
systems. They are often founded by groups or individuals with strong technical
skills and/or a background in the social services, as opposed to those with strong
management or business backgrounds.”
The KT consists of nearly 25 trustees called as general body. The NGO has clear
organisational structure. The roles and responsibilities are assigned according the
job designations clearly. At the same time like any other NGO it is also facing
difficulties due to frequent staff turnover. It is one of the biggest challenge and
deteriorating factor to run the programme effectively. The KT established its
service in almost all the districts in Karnataka. At the same time it has to improve
its administration by recruiting well trained manager and more PHC coordinators.
The management information system is effectively implemented in all the PHCs.
The PHCs are computerized and reports are submitted online. This enabled the
organisation to manage the PHCs well. The financial auditing is done regularly
every month for effective financial management.
Technical or Programmatic Capacity
The technical capacity is analysed through ability and commitment of the
organisation to provide high quality services, ongoing staff training and
75
assessment, the existence of clinical standards and other quality assurance
measures.
KT providing periodic training to its staffs including Medical officers, ANMs,
Staff nurses, Lab technicians, PHC administrators. Special trainings like training
on mental health and other programmes done twice a year. The KT having separate
training centre in Mysore which is meant for conducting training programmes.
Training has been given to the PHC staffs periodically on following subjects:
• RCH and MCH services.
• HIV/AIDS.
• IEC
• PHC Management
• Plan and budget -Accounts
• Capacity building
• Mental Health
• Traditional medicine
• Participatory Rural Appraisal
• Bio-waste Management
• VRCs in Collaboration with ISRO
The interview with the PHC staffs also revealed that the training programmes are
conducted regularly. The training programmes increase the technical capacity of
the staffs which will leads to provide quality of service to the community.
Nevertheless, for assessment of the staffs KT doesn’t have any internal appraisal
system. The assessment of the staffs which will help the organisation to identify
76
the training and development needs of the staffs. Based on the depth of needs, the
organisation can structure the training programmes.
The first PHC adapted by the Karuna Trust was Gumballi PHC which is
undergoing NABH accreditation. It will improve the quality of service provided
according to the clinical standards. And for the rest of the PHCs, IPHS standard
guidelines are followed.
However, the KT maintaining nearly 50 PHCs in different states it is a difficult
task to implement this standards simultaneously. To proper implementation of
these standards the KT has to improve its managerial capacity.
Community support
The support of the community for the success and sustain of the programme make
a difference. How people accepted the services provided what are their opinions
about the programme? How they will support the programme if programme is
successful? , are some of the very important questions to be addressed. Nearly 100
beneficiaries are interviewed in two PHCs, the results are below.
Table: 4.9: Opinion about continuation of programme
Question
Continuation of
programme
Opinion ________
__
Kallusadarahalli
Pattanayakahalli
No
No
Yes
Yes
42%
52%
4.0
78.0
N=100
In two PHCs 100 beneficiaries are interviewed, fifty from each PHCs.
Beneficiaries of the Pattanayakahalli PHC says “the quality of service improved
after the Karuna trust took over the PHC, so the programme has to be continued.”
77
Out 50 interviewed 78% agrees to continue the programme and 4% says no to
continuation and rest 18% is not aware of the programme.
The results of the Kallusadarahalli PHC are opposite to that of Pattanayakanahalli.
Nearly 42% of the beneficiaries out fifty interviews taken agree to continue the
programme, but maximum percent of people 52% are against the programme
continuation.
Table: 4.10: Measures to support the programme
Type of support
1. Pay for Service
2. Protest with elected
representative______
3. Do nothing
Pattanayakanahalli
18%_____________
54%
Kallusadarahalli
0%_____________
40%
10% (18% are not
aware of PPP)
54% (6% not aware)
N=100
In two PHCs 100 beneficiaries were interviewed. And three options were given to
the beneficiaries regarding what kind of support they can provide to the KT if the
government stops funding results in discontinuation of the programme. The options
were paying for the service, protest to continuation of the programme with the
political leader, do nothing.
Out of 50 interviewed in Pattanayakanahalli PHC 18% of the beneficiaries are
ready to avail the service paying user fees. And 54% of the beneficiaries are ready
to protest for continuation of the programme and supporting the Karuna Trust. And
10% of the people said they are not going to do anything.
When beneficiaries interviewed in Kallusadarahalli PHC, out 50 beneficiaries no
one is willing to pay for the service and maximum 54% of the people are against
the programme and they are not going to do anything. And 40% of the
78
beneficiaries said they will support the continuation of the programme by
protesting with the support of elected representatives.
The support of the community reflects the quality of service provided. Where there
is quality of service is good more likely to get the support of the people. The poor
quality of service in another PHC results in less support from the community to
continuation of the programme.
Key-stakeholders perspectives about the sustainability
The perspectives of the key-stakeholders of the NGO about sustainability are that,
the PPP brought positive health outcomes to the community due to its efficient and
equitable health care service and it was successful to improve the health condition
of people. The people will support the programme and ensure the continuation of
the programme. The people from the same community where PHCs are adapted are
recruited for certain post, so the KT was able create job for the community people.
So obviously KT will get the support of the community.
When it comes to finance they agree that if the government stops funding the
partnerships the organisation doesn’t have any other alternative sources of funding.
So if the government stops funding for the long duration definitely it will leads to
end of the partnership.
In the case of government stakeholders the Pattanayakanahalli PHC is successful in
providing quality care to the community at free of cost. The PPP will continue if
the same kind of quality ensured in the future with the support of the government.
The government stakeholders of Hassan district who are responsible for managing
Kallusadarahalli PHC having different opinion about the sustainability. In their
opinion the PHC failed to achieve its objectives. People complained about the
79
quality of services provided in the PHC. The community people are having
negative opinion about the quality of services as well as partnerships. The issues
already raised in the Taluk Panchayat and District Panchayat meetings. People
protested against PHC with the support of their political leaders. So if the same
condition going to continue definitely the partnership is going to end.
80
Conclusion and recommendations
The partnership with Karuna Trust was initiated in the year of 1996 with handover
of Gumballi PHC in Yelandur Taluk, by government of Karnataka. Later on nearly
30 PHC are contracted out within the duration of 14 years. The initiation was taken
by Karuna Trust to provide the primary health care. The NGO submitted the
proposal to the government of Karnataka and DOHFWS handed over the PHCs.
No bidding process is involved for handing over these PHCs. The policy IPP9 after
HSR made the government to come into partnership with private players.
The NGO is selected based on eligibility criteria and other terms and conditions
mentioned in the ‘Arogya Bandhu Scheme 2008’. The community need assessment
done after the PHCs are handed over to the KT. The contract is designed such that
there is clarity on the services to be provided. The partners have got the autonomy
to take its own decisions.
The PHCs are handed over for the initial period of 2 years and then the renewal
done for another 3 years after evaluation of the PHC. The financial support from
the government has increased from 75% to 100% understanding the burden on
NGOs.
The PHCs are monitored by the same officials who are monitoring others PHCs in
districts. But the monitoring and evaluation is not done regularly and there is a
misconception about the PHCs handed over to KT (lower level officials).
However, the PHCs are handed over to the NGO without prior consultation of the
community. Initially there was kind of resistance and protests against the
implementation of the programme. The awareness programmes were not done
about the PPP which may have great impact on sustainability of the model.
81
The success of the partnership also depends on the exchange of information and
communication between the partners. The study revealed that there is no regular
exchange of information between the partners. The DHO and THO also should
participate in planning of activities.
The contractual trust doesn’t exist in the government officials. This is critical to the
partnership. Since the government partnered with NGO probably the goals are
similar which involved similar benefits and less risks between the partners. But the
performance of the programme influence the public image of the PHC, if it
performs well there is a meaning for partnership.
Although, ARS and VHSC committees are formed in each PHC, they are not
empowered and trained accordingly to utilise the funds according to guidelines.
The community people are not in a position to question the services offered and
about the financial management. The accountability cannot be ensured until the
community is capable of questioning.
The salary is completely given by the government according to the scheme
Aroghya Bandhu. The financial assistance is also given for drugs and vehicle
maintenance. But the financial flow is not regular which is hampering and burden
to the NGO which is completely depends on government funds and donor
agencies.
Out of the two PHC’s investigated the quality of service provided in one PHC is
excellent where as other PHC performance is awful. The structural indicators in
one PHC are outrageous and the condition of the PHC was haphazard due to
various reasons.
The performance of PHC depends on continuous monitoring from KT as well as
form government side. The government official’s opinion towards the PHC and
82
their perspective about the partnership is not much positive. There was a
misconception about the PHC’s handed over to the KT.
After partnership, changes happened in several terms. There was change in
infrastructure, human resources and quality of services provided. And also some
new types of services were introduced. But the changes are not applicable for both
the PHCs investigated. Instead of improvement there was decline in quality of
service provided in Kallusadarahalli PHC.
The new types of service introduced also called innovations are not successful due
to various reasons. The reasons include lack of human resources, lack of training
and lack of equipments to manage these innovations.
The PPP model is sustainable until the government provides financial support
continuously. The NGO is already facing problems with delayed release of salary
grants. The salaries are paid after 8-10 months once to employees which is a de
motivating factor this may leads to frequent turnover of staffs. Since the
organisation is very old and reputed it is sustained irrespective of these problems.
Out of two PHCs investigated P.N. Hallli PHC received positive feedback and
nearly 78% of the people agreed for the continuation of the programme. But in
Kallusadarahalli PHC, 52% of people opinion about continuation of the
programme is negative. Community support is also important component for
success and sustainability of the PPP model.
83
Recommendation
The above analysis helped to draw some lessons for both the partners. It is very
essential to incorporate some suggestions below for success of the partnership and
achieve the objectives of partnership.
The success of the partnership depends on the involvement of the both the partners.
The PPP is not the panacea for the poor public health system. There is a need for
continuous monitoring and evaluation of the PHCs to improve the quality of
service provided. Both the partners should strengthen the monitoring and
evaluation system.
It is very essential to consult the local community leaders as well as the people
before handing over the PHCs. This will avoid future conflicts and reduce the
resistance from the community. The community need assessment should be done
before handing over the PHCs to the partners. This will enable to design need
based, people centred, demand driven programmes.
The transparent competitive bidding process for the selection of NGOs will enable
the government to choose the best partner as well as it will provide a fair
opportunity to many organisations.
The renewal of the PHCs should be done only after auditing and evaluating its
previous performance. The opinion of the beneficiaries has to be collected before
approving for the continuation of the programme.
The prejudice or misconception of lower-level government officials may
jeopardize the progress of the PHC.
The awareness programmes should be
conducted for lower-level officials regarding the public-private partnerships. The
PPP will successful when there is regular exchange of information through regular
84
meetings, involvement in decision making, and joint planning of activity of the
partners. The innovations like mental health, telemedicine, IEC activities making
difference to the community. The support of the government officials at the district
level and joint planning of these activities will sustain the programmes introduced.
The KT can sustain its innovation through proper allocation of the resources and
proper deployment and training them for the same.
The strengthening of ARS and VHSC committees through training programmes
regarding their responsibilities will enhance the functioning which will ultimately
results in increased accountability and transparency. These committees can ensure
proper utilisation of the funds according to the guidelines leads to further
improvement of service delivery.
The KT has to fill up vacancies in the PHCs and should provide with renovated
quarters to the staffs to ensure 24 hour services. The organisation has to ensure the
staying of the medical officers in the head quarters. And also the administrative
department has to be strengthened with more number of coordinators and qualified
managers for the smooth running of the PHCs.
Timely release of funds from the government will stop the frequent turnover of
staffs in the PHCs. The delayed grant release will affect the sustainability of the
organisation.
85
Appendix I
INDEPTH INTERVIEW GUIDE FOR KEYSTAKE HOLDERS
Name:
Designation:
Adress:
• Initiation
1. Motives for initiation
a) Who initiated PPP?
b) What motivated you to come into the PPP?
c) What was the need for the PPP?
d) What made you to come into the PPP?
e) Any incident (public health problem)/ Policies made the PPP to occur?
2. Description of partnership
a) Type of partnership
b) Nature of partnership
> Contract
> Collaboration
> Complementary
> Consultative
> Active/passive
3. Processes of creating partnership
a) What were the challenges in bringing two partners in the PPP?
b) How was the relationship between two partners?
86
c) Whether there was clarity of purpose and beneficiaries were kept in mind in
the PPP?
d) Whether any legislation/policies were made before PPP?
e) Whether there was any clarity on commitment?
f) Whether the participatory approach (beneficiaries’ participation) was there
during initiation of PPP?
g) Any community need assessment was done before the initiation of PPP?
h) What were the criteria used for selection NGO?
i) How was the selection done?(transparency)
4. Design of contract
a) Performance specification
> Services to be provided
> Description of the task
> Intended health outcomes of PPP
> Measurable indicators for the outcome(processes quality indicators)
> Time frame
b) Monitoring of the performance
c) Financial arrangement/mechanism
d) Dispute resolution
• Implementation
1. Is there any regular exchange of information/communication between the
two partners?
2. Whether the shared goal and trust with which the PPP was initiated even
continue now?
3. Whether the benefits mentioned during contract has now been provided to
the community?
87
4. Whether the partnership enhanced public image of the both the partners?
5. Whether the NGO has been given the managerial independence or autonomy
from the government?
6. Is there any hierarchy between partners?
7. Whether the government has put in necessary governance structure
(technical expertise) to oversee the implementation?
8. Monitoring and evaluation is done at regular intervals?
9. Do the NGO and government engage in joint planning and activities?
10.
Is there any readdress mechanism from the government if any one of
the partners violating the contract?
11.
Were the partners open for negotiation of the contract after selection
and during implementation?
12.
Was there any outcome that was not intended to occur?
13.
Whether the benefits and risk are equally shared between the partners?
14.
Any training or capacity building was done by the government to the
workers of the programme?
S Accountability
15)
How the partners are held accountable?
16)
Who does this accountability (govemment/community)?
S Finance
17)
What was the protocol accepted in the contract for funding?
18)
Is the funding from the government is regular or delayed?
19)
Grants are given in prospective payment or retrospective payment?
20)
If retrospective payment, whether it is based upon the targets or
auditing within government)
1
88
21)
How is the expenditure pattern monitored(funding)?
22)
Any time you overshoot or underutilized the budget?
• Sustainability
1. Whether the PPP has brought positive health outcomes to the community?
2. Whether the government is giving funds as per the agreed terms?
3. How will the programme continue if funding stopped?
4. Do you have any alternative sources of funding (user fees)?
5. Whether the community is willing to continue the program, if government
withdraws its participation or contract?
6. Whether any people were employed from the community to run the
programme?
SEMI STRUCTURED INTERVIEW FOR BENEFICIARIES
Name:
Adress:
1. Are you aware that the government is in partner with NGO to deliver the
programme? If yes, how do you know about it?
a. Yes
b. No
if yes,-------------------------------------------
2. For how long have you been availing these services?
3. What kind of benefits you avail from this programme?
4. These services offered at free of cost. Apart from these do you incur any
other cost?
5. Do you get the medications regularly and free of cost?
6. Was there any meeting or consultation done for initiation of this
programme?(probe)
89
7. How did you came to know about this programme?( probe reg publicity
and awareness)
8. What are the changes you have observed after implementation of this
programme?
a.
Infrastructural changes: New building has come up, New vehicle is
coming for service, IEC boards have been put inside and outside the
hospital, New equipments have been bought, No of beds have been
increased
b.
Human resource changes: Doctor,
Staff nurse, Health animators,
Driver, Lab technician
c.
New services offered:
d.
Number of tribal accessing the service has increased: Yes/ no
9. QUALITY OF SRVICES:
a. Whether the provider spent sufficient time with you: yes/no
b. Whether the provider listened patiently to what you say: yes/no
c. Whether the provider explained all the things clearly to you: yes/no
d. Whether the services are available at convenient time: yes/no
e. Whether the services provided at the time they promised to do so:
yes/no
f.
Do you feel that you have to wait for a long time to see the provider:
yes/no
g- Is there any instance you had to come back for the same complaint
again: yes/no/NA
h. For next level of care, guidance was done properly : yes/no
90
10. Do you think the quality of services provided is increased or decreased after
the implementation of this programme? Yes/no
11. Was there any community feedback done regarding the implementation of
the
programme?
12. What are the problems you face from this programme?
13. What do you do when you face some difficulty in the service
delivery?(probe reg monitoring)
14. Do you attend the village/area level meeting? If yes what are the issues
discussed? Did you give any recommendations?
15. If yes, did they consider your recommendation?
16.1s there any way you are involved in the programme? If yes, why and what
is the nature of involvement?
17.Do you feel you derive benefits from this programme and this has to
continue? Yes/No
18.If the government stops funding, what measures you will take for the
continuation of this programme?(probe regarding )
I will support with trained manpower
I will pay for the services for the continuation the programme
I will protest with the elected representatives for the continuation of
the programme.
91
SEMI STRUCTURED INTERVIEW SCHEDULE FOR PROVIDERS
Name:
Designation:
Nature of work /job responsibilities:
1. How long have you been working for organisation—
2. Are you aware that the government is in partner with NGO to deliver the
programme? If yes, how do you know about it?
b. Yes
b. No
ifyes^--------------------------------------------
3. How were you part of the initiation of this programme?(probe reg
meeting/consultation and recommendations given/taken)
4. What are the new types of services provided after the PPP?
5. How was the publicity/awareness created among the community for the
programme?
6. What is the nature of work you do for this programme?
7. Did you undergo any special training for the work? Is your job description
updated regularly?
8. What are the changes you have observed after implementation of this
programme?
e. Infrastructural changes: New building has come up, New vehicle
is coming for services, IEC boards have been
put inside and
outside the hospital, New equipments have been bought , No of
beds have been increased
92
f. Human resource changes: Doctor, staff nurse, Health animators,
driver, lab technician
g. New services offered:
9. Do you feel that the number of patients accessing the service has
increased: Yes/ no
10. If yes, could you maintain the same quality as-before?
11. Is there regular supply of medicines and other commodities necessary
for this programme?
12. What are the problems/difficulties you encounter during implementation
of this
programme?
13. Have you given any suggestions/ recommendations to modify the
programme and whether same has been accepted?(probe reg meetings for
the programme)
14. How is your work supervised or monitored pertaining to this
programme?( govt officials monitor, meeting are conducted, based on
reports)
15. Do you get any incentives for better performance?
16. Has the public image of the PHC has gone up after PPP?
17.
Have you been held accountable by the community for providing
services( protest
and complaints)
93
18. Do you feel the community is deriving benefits out of this programme
and health
status has improved after the programme? Yes/No
19. Can you explain about the community participation in this programme?
20. If the government stops funding, how can the organisation carry on the
programme? Probe regarding... (User fees, organise people to demand
for
continuation of the programme)
94
Appendix II
GOVERNMENT OF KARNATAKA
AROGYA BANDHU SCHEME FOR INVOLVING PRIVATE MEDICAL
COLLEGES AND OTHER AGENCIES IN THE MANAGEMENT OF PHCs
Under Partnership Agreement
July 2008
GOVERNMENT OF KARNATAKA DEPARTMENT OF HEALTH &
FAMILY WELFARE
Scheme for involving All Medical Colleges (Govt. /Private) and others
Agencies in the Management of PHCs
1. This scheme provides an opportunities for Private Medical Colleges, NonGovernmental Organisation (NGOs), Trusts, other Charitable Institutions
and Philanthropic Organisations etc. either to fully manage the PHCs with
financial assistance by Govt, of Karnataka or to contribute to the
improvement of the facilities or to improve of service delivery without
directly managing the PHCs.
2. Primary Health Centres (PHCs) as per criteria laid down in 3 below can be
given on partnership agreement, on contribution or any innovation within
the state policy (Refer Para No. 20):
3. PHCs shall be selected as under:
(a) PHCs which are low in performance i.e., having high IMR & MMR and
low coverage on immunisation or low institutional delivery.
(b) PHCs with more number of vacancies for long duration.
(c) C’ category PHCs which are more than 15kms. away from highways.
(d) The proposal should be approved by the District Health Society of the
concerned District.
4. The PHCs with above said criteria can be given on Partnership Agreement.
95
The initial contract will be for five years with clause of renewal every year
based on review of performance.
5. If, for the purpose of improving either the infrastructure or the service
delivery, any institution comes forward with contribution in cash or kind,
the same will be permitted for any PHC in the State.
6. Eligibility Criteria:
a) All govt./private medical colleges are eligible to take up the PHCs for
management, under this scheme.
b) Any Non-Governmental Organisation willing to participate in this
scheme:
i) Should be working in rural areas with legal status of a society
registered for three years under the Societies Registration Act or
any corresponding State Act or as a Trust registered under the
Indian Trust Act, 1882 or the Charitable and Religious Trusts Act,
1920.
ii) The NGO Should be active and its financial position should be sound.
This should be evident from the audited statements of accounts for
the past three years.
Note: ‘A’ category PHCs which are located within lOkms of the taluka or
District Headquarters, ‘B’ category PHCs which are located between 10 to
15kms. of taluka and District Headquarters, ‘C’ category PHC which are
located more than 15kms. of taluka and District Headquarters.
iii)
The NGO should be a reputed one with demonstrated capacity and
dedicated management body.
iv)
The NGO should not have been a defaulter in respect of any funds
received from any of the Government Departments.
v) The NGO should have been working in the same district, at least for two years,
where it proposes to take a PHC for management.
c)The Trusts sponsored by the reputed corporate bodies, with proven managerial
capacities, are also eligible to take PHCs for management.
96
7. Procedure for submission of Proposals on invitation of the Expression of
Interest by the Department:
a) The govt./private medical colleges or the Trusts, running the Medical Colleges,
shall submit their applications to the Commissioner of Health and Family
Welfare Services, Ananda Rao Cirlce, Bangalore, through the District Health
Society.
b) A Medical College can submit the proposals to manage upto a maximum of
three PHCs in the first phase.
c) The NGOs and corporate bodies shall submit their application to the
Commissioner, Health & Family Welfare Services through the District Health
Society of concerned District.
d) An NGO can submit a proposal to manage one PHC per district in the first
phase.
e) A Trust sponsored by a corporate body can submit a proposal to manage upto
two PHCs in the first phase.
f) All applications, from medical colleges, shall be accompanied by the
information to be furnished in the manner provided Appendix-I.
g) The applications of NGOs shall be accompanied by the information to be
furnished in the manner provided in Appendix-II.
h) The applications of Trust, sponsored by the corporate bodies shall be
accompanied by the information to be furnished in the manner provided in
Appendix-Ill.
8. Evaluation and Selection :
a) The proposal of the Medical Colleges or NGOs or the Corporate Bodies shall be
first scrutinized by the District Health Society, with reference to the eligibility
criteria’s. The PHC should be selected by the department within the above said
6C’ category area. The applications will be forwarded to the Commissioner,
Health & Family Welfare Services after duly recording of opinion on the above
points.
b) In respect of the NGOs, the CEO should also record his / her opinion clearly
indicating whether the NGO is working in the District atleast for 2 years and
qualify as per his assessment.
97
c) Selection Committee: A selection committee, with the following composition,
shall consider all the proposal received in the Commissioner’s Office and take a
final decision within one month of the receipt of the proposal by the
Commissioner. The Committee shall consist of:
Commissioner,
Chairman
i.
HFWS
ii
Mission Director
Co-Chairman
iii
Member
. Director - HFWS
iv Chief Executive Officer ZP
. concerned
Member
Member
v. Additional Director (PHC)
vi Chief Accounts Officer & Financial
Membe
. Advisor
r
vii. Deputy Director (PPP)
Member
Membe
viii. A reputed doctor
r
ix
. A reputed person in the field of
Member
Public Health
The Selection Committee will also
x. have
Member
Director, Medical Education as
member for
Considering the proposals received
from
the Medical Colleges on
invitation
xi Joint Director, Health and
. Planning
Member
Convenor
d) The Committee will evaluate the proposals with reference to the
information furnished by the medical colleges / NGO / Trust and the
recommendations of the District Health Society and then take a final
decision.
e) The Director Health & family Welfare Services shall communicate the
sanction /rejection of the proposal to the Medical College/NGO/Trust.
98
The approved agency shall enter into a contract with the Director of
Health & Family Welfare Services in the form given at Appendix-V.
9. Constitution of Arogya Raksha Samithi:
These PHCs will also have a Arogya Raksha Samithi as per the guidelines
issued by the department.
10.
Management of the PHCs by the Agency:
a) The agency i.e. Medical College / NGO/ Trust shall take full
responsibility for providing all personnel at the PHC and the sub-centres
coming within its jurisdiction.
b) All personnel working in the PHC shall be employees of the agencies.
c) All existing staff of the government, working within the jurisdiction of the
PHC, may be withdrawn by the Department for re-deployment elsewhere.
However some personnel may be retained, on deputation basis, by mutual
consent of the agency.
d) All personnel appointed, by the agency, has to be in accordance with the
staffing norms of the department in the PHC / sub-centre and have the
qualification prescribed in the department for such personnel.
e) The agency shall employ the personnel with at least minimum
qualification prescribed by the Government.
f) The agency shall be free to fix the remuneration of its employees not less
than fixed by the govt., However the salaries of the employees, on
deputation from Government, shall be governed by the terms of
deputation. The agency shall furnish to the Commissioner, Health &
Family Welfare Services, the details of remuneration it is paying to its
employees in the PHC.
g) Every PHC should have a minimum staffing pattern like a Medical
Officer, Staff nurse, Pharmacist, Lab technician and LHV to render good
services in preventive, promotive and curative aspect.
11.
Responsibilities of the Agency:
a) The agency shall be responsible for the implementation of all the
99
National and State Health & Family Welfare Programmes and the
Health Care Service delivery within the PHC. No patient shall be
charged any amount for diagnosis, treatment, and drugs or for any other
purpose except in accordance with the Government policy.
b) The agency will be responsible to treat the Medico legal cases as per the
guidelines.
Assets of the PHCs:
a) The existing assets of the PHCs and Sub-Centres, coming under its
jurisdiction are to be handed over to the agency for the duration of the
entrustment.
b) The assets shall be maintained by the agency.
c) After the agreement period, all assets shall be returned to the Government,
in proper condition, subject to normal wear and tear.
d) The Agency will be free to make any additions to the fixed assets, with
prior written consent of the District Health & Family Welfare Officer, by
furnishing the details of the proposed changes to the fixed assets.
However, any such additions shall be without costs to the Government.
12.
e) The agency shall ensure adequate stocks of all essential drugs, at all times,
for supplying them free of cost to the patients.
f) If any of the staff appointed in the PHC proceeds on a long leave, beyond
15 days, the agency should make alternate arrangements to ensure
continuity of services.
13.
Funding from the Government:
For the services rendered by the agency, the Government would reimburse
the costs as per the following norms:
a) 100% reimbursement of the actual remuneration, in respect of the staff
employed by the agency subject to a maximum of the midpoint of the pay
scale in the Govt, of that category. Remuneration paid to staff in excess of
the staffing norms of the department, will be met by the agency.
b) Leave salary of the female employees, on account of maternity leave, up
to a maximum of 135 days per delivery, restricted to a maximum of two
deliveries in the case of govt, deputed staff.
100
c) The liabilities, if any, that may arise on account, of or in the course of
employment of the persons appointed by the Agency will be solely that of
the Agency and their services will stand automatically terminated in the
event of the Agency handing back the PHC to the Department for any
reasons whatsoever.
d) POL charges with a ceiling of 100 litres per month, if the agency provides
an exclusive vehicle to the PHC.
e) Full reimbursement of Phone, water and electricity charges subject to a
maximum of Rs. 1,500/- a month.
f) Budget for drugs in the scale determined by the Government from time to
time for all PHCs in the State (the present scale is Rs. 1 lakh per annum).
g) Advance for one quarter will be placed at the disposal of the agency out of
NRHM/KHSDRP fund and subsequently recouped from ZP funds. The
grants for 2nd quarters will be released when UCs/SOEs for the 1st quarter
is furnished. This system will be rolled for every subsequent quarter.
h) Any assistance given from NRHM, Central govt, or State govt, to any
govt. PHCs, the same assistance will also be given to the PHCs is under
the Partnership Agreement. This will be managed by the THO in
consultation with the managing NGO/ administrative doctor.
i) The funds to the agency shall be released by the District Health & Family
Welfare Officer as per (g) above from out of the District/State sector
budget.
14. Monitoring:
The District Health & Family Welfare Officer, Taluk Health Officer and
District Project Management Officer shall monitor the working of the PHC
with reference to the services rendered by the PHC under the National and
State Health & Family Welfare Programmes and provisions of general health
care services in the PHC as per the general directions of the Government.
The suggested indicator for monitoring the performance is given in a
Appendix iV, Table 1.
15. Co-ordination:
To ensure there is proper co-ordination between the agencies to whom the
101
PHCs are entrusted for management, the District Health & Family Welfare
Officer and the Zilla Panchayat, there shall be a Co-ordination Committee
with the following composition:
Chairman
a) Commissioner, HEWS
Co-Chairman
b) Mission Director
Chief Executive Officers of the
c) respective ZP
Member
Chief Accounts Officer and Financial
Member
d) Advisor
Member
e) Deputy Director (PPP)
Member
Convenor
f) Joint Director (Planning)
The Co-ordination Committee shall meet at least once in three months in the
first year and at least once in six months thereafter to address all issues of co
ordination between different agencies. The Committee is fully empowered to
issue any clarifications and administrative directions which will be binding
on all concerned.
16. Period of Entrustment:
The entrustment of PHCs to Medical Colleges / NGOs / Trusts will be for a
period of two years subject to review and confirmation of the arrangement
after one year and can be extended upto five years. Each intervention shall be
evaluated in fifth year on the basis of the experience of the past four years.
Renewal of the entrustment will be considered on the basis of the evaluation
conducted by an external agency.
17. Power to give directions:
During the period of entrustment, Government may, in public interest, give
directions to the agency and these directions would be binding on the agency.
However such directions can be given under specific extraordinary situations
and will be related only to service delivery. The reasons for such directions
should be included in the communication sent to the agency.
Only the Director, Health & Family Welfare Services or any higher authority
would be competent to issue any such directions.
102
18. Accounts:
The agency entrusted with the management of the PHC shall maintain
separate accounts and cash book for the PHC.
19. Audit:
Every agency, to which the management of a PHC is entrusted, shall furnish
Annual Audited Statement of Accounts within three months after the closure
of the Financial year. Government reserves the right to order special audit of
the accounts at any time during the period of entrustment or within one year
after the closure of the entrustment.
20. Termination:
Government may, at any time, terminate the contract for violation of the
conditions of contract by the agency, after due enquiry into such violations.
The selection committee, under the Chairmanship of the Commissioner, is
empowered to consider the report of enquiry and take a final decision in the
matter. Similarly the agency may also terminate the contract by giving 90
days notice in writing Termination of Contract by the agency, without notice,
will entail penalties equal to the amounts due for such duration.
21. Closure:
Either on completion of the entrustment period or on termination of contract
by either side, the agency shall hand over the possession of all assets
originally given to the agency, by the Government, as well as the any assets
added to the institution with the prior written consent of the District Health
and family Welfare Officer.
22. Contribution to the PHCs and Sub-Centres:
Any charitable or philanthropic organisation, Trusts, NGOs, Corporate
Groups and individuals can contribute to the improvement of infrastructure /
service delivery at the PHCs and sub-centres. The nature and extent of such
contribution will be decided between the concerned donor and the
H c —' 0°
103
Committee. For permanent development works donors will be permitted to
put up a stone slab in that institution inscribing thereon the name of the donor
and the nature of the contribution. If the contribution is towards the
improvement of services for certain duration, the Donor is permitted to put
up a board for that duration, with details of the contribution and the purpose.
The components for contribution:
23.
The contribution may be given for any of the following component:
Equipments and furniture’s.
Computers.
Additional requirement of drugs and chemicals.
Water and toilet facility to the hospital.
Construction and renovation of the existing building.
Provision of developing hospital garden and fencing or compound.
Strengthening of Laboratory.
Provision of solar water heaters.
Providing non-clinical services - PHC complex.
Provision of Ambulance Services in PHC area (Taluk).
Provision for water purification system.
Provision for Bio-medical waste management.
Building maintenance.
Provision of Specialist Services.
Conducting camps.
24.
Acceptance of Contributions:
• The proposal of contribution will be made by the donor to the Arogya
Raksha Samithi. The Arogya Raksha Samithi will take a decision on such
contribution and accept such contribution, if they are without any attached
conditionalities (except the conditionality of proper use).
• If any conditionalities are attached to the donation/contribution which
imposes financial liabilities on the Arogya Raksha Samithi either in short
term or long term, then the proposal will be referred to the District Health
Society for appraising the proposal.
• If contribution is for civil works (construction or renovation) it will be
104
decided by Arogya Raksha Saminthi if it is within Rs. One lakhs . Beyond
this it will be referred to District Health Society for Approval.
• If contribution is with condition of displaying the name of the donor, the
same will be referred to the District Health Society for decision.
25.
Application of the Contribution:
Where the Contribution is for additions to the building, the work shall be
executed either by the ZP Engineering division or by the Contractor engaged
by the Donor under the supervision of the ZP Engineering Division. If the
contribution is for adding any equipments etc. or providing drugs, the donor
may provide the same as per the specifications; requirements to be furnished
by the District Health and Family Welfare Officer. If the contribution is in
the form of providing the services of Medical / Paramedical personnel the
donor could make available only person of integrity and required
qualifications and position them in the PHC. Such persons shall be paid
directly by him. Once positioned for a specified period the persons sent shall
work under the control and supervision of the Taluk Health Officer / PHC
Medical Officer as the case may be.
APPENDIX-I
Important Instructions
1. Please ensure that the following documents are enclosed while submitting the
proposal.
i.
Memorandum and Articles of Association / Bye Laws of your
organisation.
ii.
Copy of registration certificate under these Acts, whichever applicable.
a) Societies Registration Act, 1960.
b) Indian Trusts Act, 1882.
c) Charitable and Religious Trusts Act, 1920.
105
d) Foreign Contribution (Regulation) Act, 1976.
e) Any other Act.
iii.
Copies of exemptions granted by Government / Local Bodies for Sales
Tax, Income Tax etc.
2. Person signing this form should be the one so authorised by the Articles of
Association / Bye Laws of the Institution. Otherwise authorisation by
resolution of the executive body for the person signing should be enclosed.
3. Please state how you propose to bring any value addition to the services
rendered from the PHC.
APPENDIX-n
FORM II
INFORMATION REGARDING MEMBERS OF PRESENT
EXECUTIVE BODY
Money
value
Whether
OJJice field in
Occupat
SI. Name / Designat Qualifica related to benefits
other
ion
tion
other from NGO Age ion
NGOs with
No. Address
(in
Address
office
Kupees
bearers
1
2
3
4
5
6
7
8
9
106
1. For column 6: Salary / Honorarium / any other perks / housing
/transport.
2. Write F for farmer / B for Business / G for Government, Semi
Government Employee / H for House-Wife / P for Professional / O
for others.
APPENDIX-II
FORM IV
DETAILS OF ACTIVITIES
SI.
Titla of
Scheme
Funded by
District
2
3
4
No.
1
Geographical area of
operation
Completed Measures
on
taken for
Amount in
Rupees
^oing sustainability
5
6
7
107
No. of Staff working on
Full time basis
Part time basis
Voluntary basis
Total No.
Are there any paid staff related to office bearers / board members /
executive members of NGO. If yes, furnish detail.
APPENDIX II
FORM V
FINANCIAL STATUS OF ORGANISATION
Please provide copies of (i) Annual Reports Audited Income /Expenditure
Account (ii) Receipts / Payments Account (iii) Balance Sheet & (iv) Bank
Pass Book for the past 3 years.
Income and Expenditure:
SI. No.
1
2
Year
Income (Rs. In
Lakhs)
Expenditure (Rs. In
Lakhs)
3
Major assets of Organisation as per last Audited Balance Sheet (this includes
land value, building with plinth area etc.)
Expenditure (Rs. In
SI. No. _____________ Assets
Lakhs)
1
Cash Deposits______
2
Movable Assets_____
3
Immovable Assets
(Please attach list of all movable and immovable assets of value over
Rs. 2,000/-) Any exemptions received from Government Yes / No.
(If yes,
108
specify)
Details of Bank Accounts from which Government funds are proposed to
be operated:
Account in the name of:
Details of Bank Account:
SI.
Items
No.
1
2
3
4
5
6
7
8
9
10
Name of the Bank____________
Full Branch Address__________
Account No._________________
Type of Accounts____________
Name of the Signatory (1)_____
Post held in organisation_______
Relationship to Chief functionary
Name of the Signatory (2)_____
Post held in organisation_______
Relationship to Chief Functionary
Name of Signatory (3) post held
11 in
organisation
___________
Relationship to Chief
12 functionary
Details
Details
Details
109
APPENDIX IV
Table 1: Proposed Indicators for the Partnership Agreement
Indicat
or
Baseline data Target for
end
data for
Means
of
nrniect area
measnr
Maternal Mortality Rate- (NRHM
goal less than
100 per lakh deliveries)
a) % of safe deliveries
b) % of institutional deliveries
c) % of identification of high risk
pregnancy
d) % of pregnant woman
DLHS/R
CH
Survey/H
MIS
Infant Mortality Ratea) % of children exclusively
breast fed b) % of fully
immunised children
c) % of children treated for ARI
Percentage of out patients treated
DLHS/R
CH
Survey/H
MIS
Percentage of in patients treated
Tuberculosis (RNTCP guidelines)
a) Screening of chest
symptomatics (2% of the
new adult OPD- Sputum
referral)
b) Smear collection rate (three
Malaria
a)
Active surveillance (1% of
the population) b)
Passive
surveillance (15% of the new
OPD) c) API_________________
Leprosy
DLHS/R
CH
DLHS/R
CH
DLHS/R
CH
Survey/H
MIS
DLHS/R
CH
Survey/H
MIS
DLHS/RCH
110
population
b) Detection rate per
population (ANCDR-
1 lakh
Annual
Survey/HM
IS
________________________ NIpw
Filaria- Filaria Endemicity Rate
(clinical case or slide positive case
HIV/AIDS/STD
a) Incidence of HIV
Blindness Programme- Percentage
of cataract operation done or no. of
Mental Health- Prevalence of mental
illness
Iodine Deficiency DisorderPrevalence IDD cases or goitre
Health related programmes
ICDSa) Percentage of Anganawadi
______ Mpalth rhprV- nn_______________
Water supply and sanitation
a) Percentage of villages
/families access to safe
DLHS/R
CH
DLHS/R
CH
DLHS/R
CH
DLHS/R
CH
DLHS/R
CH
DLHS/R
CH
Survey/H
DLHS/R
CH
Survey/H
_________ wrotAr gnTT»1tr____________________________
NA=not available, HHS=household survey, HMIS=health
management information system, HFA=health facility
assessment,, FIC = fully immunized child
NOTE: The targets in this table are meant to be indicative and
not exact. What will matter is significant progress along these
parameters in the Partnership Agreement area.
Additional indicators to be followed are outcome indicators. They
are influenced by many factors, PHC services being one of them.
They are typically:
Under five mortality rate,
Ill
- Maternal mortality rate,
- HIV prevalence rate,
- Malaria prevalence rate.
APPENDIX V
CONTRACT FORM
Stamp Paper
Worth Rs.200.00
THIS AGREEMENT made
the
Between Governor of
Karnataka represented by the Director of Health and Family Welfare
Services, Government of Karnataka, (hereinafter referred to as the “first
party”) of the other part.
WHEREAS the First Party has formulated a scheme for involvement of the
Private Medical Colleges and Non-Govemment Organisations in
management of Primary Health Centres in the State. The Second Party
who is
(Nature of the agency) is desirous of
participating in the scheme and offered its services in terms formulated by
the Government.
NOW THIS AGREEMENT WITNESSETH AS FOLLOWS:
1. Words and expression used in the agreement shall have the same meanings
as are respectively assigned to them in the Scheme notified by the
Government Organisations in Management of Primary Health Centres.
2. The Scheme notified by the Government of Karnataka for involvement
of Private Medical Collegesand Non-Govemment Organisations in
Management of Primary Health Centres shall be deemed to form and be
read and constructed as part of this agreement.
3. In consideration of the payments to be made by the First Party to the
Second party as hereinafter mentioned, the Second Party hereby covenants
with the First Party to manage the Primary Health Centres
at
(Place and District) and the sub-centre coming under its
jurisdiction and provide the services in conformity with all conditions laid
down under the said schemes of the Government of Karnataka.
112
4.
The first party hereby covenants to reimburse the amounts to the
second Party in consideration of the provision the Services stated above once
a quarter as provided in the Scheme notified by the Government of
Karnataka.
IN WITNESS: where of the parties here to have caused this Agreement to be
executed in accordance with their respective laws the day and year first
above written.
Signed, sealed and Delivered by the
Signed, sealed and delivered by the
113
References
A. Venkat Raman and James Warner Bjorkman, 2009. Public-Private Partnerships
in Health Care in India (Lessons for developing countries), First published by
routledge.
Allen, P. 2002. A Socio-Legal and Economic Analysis of Contracting in the NHS
Internal Market using a Case Study of Contracting for District Nursing. Social
Science and Medicine, 54: 255-266, Elsevier publications.
Alok Mukhopadhyay, 2000, Public-Private Partnership in the Health Sector in
India, ADBI POLICY PAPERS SERIES No. 1, ADBI Publishing, pg no. 333-344,
available at http://www.uhrc.in/uhgateway/documents/1073.pdf.
Bharathi Ghanashyam, September 13, 2008. Can public-private partnerships
improve health in India?, Vol 372, World report.
Berman, P. and P. Dave. 1994. Experiences in Paying for Health Care in India’s
Voluntary Sector. In Reaching India’s Poor: Non-governmental Approaches to
Community Health edited by S. Pachauri. New Delhi: Sage Publications, pp. 355373.
Deepak Mili, Public Private Partnership in Health: An Understanding of PPPs in
Primary Health Care in Arunachal Pradesh.
Denise DeRoeck, March 1998, Making Health- Sector Non- Governmental
Organisations More Sustainable: A Review of NGO and Donor Efforts, available
at http://pdf.usaid.gov/pdf docs/PNACH338.pdf.
Family Welfare Statistics in India 2011. Statistics Division, Ministry of Health and
Family
Welfare,
Government
of
India,
available
at
http://mohfw.nic.in/WriteReadData/1892s/972971120F W%20Statistics%2020 11 %
20Revised%2031%2010%201 l.pdf.
1
114
Gilson, L., J. Adusei, D. Arhin, C. Hongoro, P. Mujinja and K. Sagoe. 1997.
Should African Governments Contract out Clinical Services to Church Providers?
In Private Health Providers in Developing Countries: Serving the Public Interest?
edited by S. Bennett, B. McPake and A. Mills. London: Zed Books, pp. 276-302.
Guidebook on Promoting Good Governance In Public-private Partnerships,
UNITED
NATIONS
New
York
and
Geneva,
2008,
available
at
http://www.unece.org/fileadmin/DAM/ceci/publications/ppp.pdf.
Healthcare in India, Emerging market report 2007, PricewaterhouseCoopers.
Johannes Jutting, 13./14.12.1999, Public-private-partnership and social protection
in developing
countries:
the case of the health sector,
available at
http://www.oecd.org/dataoecd/32/47/2510186.pdf
Jose Luis Navarro Espigaresl,2, Elisa Hernandez Torres, PUBLIC-PRIVATE
PARTNERSHIP AS A NEW WAY TO DELIVER HEALTHCARE SERVICES,
available at http://www.ugr.es/~montero/XVIeepZ81 .pdf.
K. Buse and G.Walt, Global public-private partnerships: part I - a new
development in health?, Bull World Health Organ vol.78 no.4 Genebra 2000,
retrieved from http://ppp global/Bulletin of the World Health Organisation - Global
public-private partnerships part I - a new development in health .html
Narayan Ravi (2001), Karnataka, Health Sector Reforms in India, Initiatives from
Nine States, Review of Externally Aided Projects in the Context of their
Integration into the Health Service Delivery in Karnataka, CMH Working Paper
Series,
WG
6:8
at
available
http://www.whoindia.org/LinkFiles/Health Sector Reform kama-BW.pdf.
KASTURI SEN and MERI KOIVUSALO, 1998. HEALTH CARE REFORMS
AND
DEVELOPING
COUNTRIESDA
CRITICAL
OVERVIEW,
t
115
INTERNATIONAL
JOURNAL
OF
HEALTH
PLANNING
AND
MANAGEMENT Int. J. Health Plann. Mgmt. 13, 199±215.
Leena V Gangolli, Ravi Duggal, Abhay Shukla, January 2005,
Review of
Healthcare In India, Published by Centre for Enquiry into Health and Allied
Themes.
MICHAEL R. REICH, JUNE 2000. Public-private partnerships for public health,
NATURE MEDICINE • VOLUME 6 • NUMBER 6 •, available at
http://www.hsph.harvard.edu/faculty/michael-reich/files/Partnerships book.PDF.
Mona Gupta, Public Private Partnership (PPP) Initiatives in Bihar: Successes and
Failures, available at http://www.cehat.org/go/uploads/PPP/mona.pdf.
Nanette Relave and Sharon Deich, January 2007. A guide to Successful PublicPrivate
Partnerships
for
youth
programmes,
available
at
http://www.fmanceproject.org/publications/publicPrivate PM.pdf
Natasha Palmer,! Anne Mills, 1 Haroon Wadee,l Lucy Gilson,! & Helen
Schneider, 2003, A new face for private providers in developing countries: what
implications for public health?, Policy and Practice, Bulletin of the World Health
Organization,
available
at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2572436/pdf/12764496.pdf.
National Family Health Surveys 1, 2 &3(1992-93; 1995-96; 2005-06).
National
Health
System
Profile,
2010,
retrieved
from
http://cbhidghs.nic. in/index2.asp?slid=l 125&sublinkid^929.
Rama V Baru and Madhurima Nundy, January 26, 2008. Blurring of Boundaries:
Pubic-Private partnerships in Health Services in India, Economic and political
weekly,.
1
116
Ramesh Bhat, December 30, 2000. Issues in Health Public-Private Partnership,
Economic and Political Weekly
Sania Nishtar, 28 July 2004. Public - private ’partnerships’ in health - a global call
to action, Health Research Policy and Systems 2004, 2:5 doi: 10.1186/1478-45052-5, available from http://www.health-policy-systems.eom/content/2/l/5.
Shirin Bagg, January 2009. Healthcare in India Report Highlights, Boston
at
available
Analytic,
http://www.bostonanalytics.com/india watch/Healthcare%20in%20India%20Exec
utive%20Summary.pdf.
Stephany Griffith-Jones and Barbara Stallings, autumn 1995, New Global
Financial Trends: Implications for Development, Journal of Interamerican Studies
and World Affairs, Published by: Center for Latin American Studies at the
University of Miami, available at http://www. jstor.org/stable/166333.
The Emerging Role of PPP in Indian Healthcare Sector, April 2008, prepared by
CII
in
collaboration
with
http://www.ibef.org/download/PolicyPaper.pdf.
KPMG,
available
at
-F
i
Mo re Books!
publishing
4
ib
■
i want morebooks!
Buy your books fast and straightforward online - at one of world's
fastest growing online book stores! Environmentally sound due to
Print-on-Demand technologies.
Buy your books online at
www.get-morebooks.com
Kaufen Sie Ihre Bucher schnell und unkompliziert online - auf einer
der am schnellsten wachsenden Buchhandelsplattformen weltweit!
Dank Print-On-Demand umwelt- und ressourcenschonend produziert.
Bucher schneller online kaufen
www.morebooks.de
- Media
15541.pdf
Position: 2290 (4 views)