health care & PPP
In recent times, some global
partnerships have emerged to
assist countries that have
resource constraints to provide better health services to the public. Initiatives have been taken and decisions have been made so that wealthier foundations can join in partnership with health providers in countries like Nepal to contribute to basic health services. Agencies such as the Global Fund have been trying to deliver drugs to developing countries because these countries are not able to purchase the drugs at western costs. Pharmaceutical companies, as private companies, need to make profit. So many of the drugs conceived and manufactured in western countries have been inaccessible to most of the Nepalis who need them.
The building of partnership between foundations, governments and non-government agencies has meant that drugs could be developed and delivered at a cost that countries like Nepal can afford, while at the same time making sure that pharmaceutical companies don’t go broke by making drugs available at low prices. It doesn’t mean subsidizing the companies per se but encouraging them to work in partnership. Any component of this tripartite partnership in isolation would not be able to do what the combination can do. First, all the contributing parties bring finance and with that bring different capacities, skills and resources. It’s like any game in which just one member can’t ensure victory for the team. There have been institution-to-institution partnerships, single-disease partnerships (e.g HIV-AIDs) and single-organ partnerships (e.g eyes) in one location of a country. What global partnerships now need to offer is the possibility of making these kinds of contributions nationwide. Major global foundations (for example, the Bill and Melinda Gates Foundation), in combination with government and other agencies, could contribute sustantially to an entire country’s problems.
Tele-medicine, which can connect rural patients or health centres to urban experts through video conferencing and other means could be used more widely than just between one institution to another. Global organisations like the Global Fund have so far concentrated more on major communicable diseases. Non-government foundations like Gates have primarily focused on big killers like malaria, tuberculosis and HIV. There is the possibility for these kinds of partnerships to progress into other areas of providing healthcare. In particular, there is potential to move from the communicable diseases to non-communicable diseases. And the major non-communicable disease in this part of the world is trauma, followed by diabetes, heart diseases and others. All could be managed better if there were better communication between major centres teaching hospitals and district hospitals. Video conferencing could play a greater role. To my knowledge, one such association is already underway in Nepal between Dolakha Hospital and PHECT Model Hospital in Kathmandu. This could be taken as a pilot project.
The public private partnership (PPP) model has been used to address some problems in the delivery of healthcare. There have been investigations on PPP in the health sector in countries like Australia, United Kingdom, the USA and some European countries. Examples from these countries show that some of their models work while some do not. There are various ways that a single institution might engage public and private interests. So, there is no single model for doing this. There have been a number of studies comparing the efficiency of public versus private enterprise in building and running hospitals. In the USA, of 149 studies, the majority have shown that public administration is more efficient than private. So, we have to be cautious about approaching this model. We need to be aware that the private sector has to make a profit. Therefore, in the beginning of any public-private partnership there might be conflict of public and private interests.
If you look across the border in India, there is a booming private health business with private institutions serving about 300 million people. That sounds like an amazing delivery of healthcare. But, in the meantime, there are about 800 million people who are not able to access the private system because they are too poor to pay and the public system is not catering sufficiently to them. There is little engagement of Public Private Partnership in catering to that big bulk of the population. The private institutions are keen on catering to the 300 million who can pay. In the USA, which is dominated by private institutions, the situation is similar with one-sixth of its population (50 million people) unable to access adequate healthcare. So, the private-driven health sector doesn’t provide for everybody. In this regard, a stark contrast has been provided by National Health Services.
The United Kingdom is one good example. New Zealand and Australia are also dominated by National Health Services though there are private players as well. Due to the existence of the National Health Service, any member of a community can access the health service since it’s a universal access system which ensures equity. Now it can be said that a public system is not as good as a private system but, in fact, that is not entirely true and it depends upon what aspects of medicine you are looking at. The private sector focuses on those aspects out of which they can earn more profit. So, they are not going to provide services to the same extent for mental health for example, or, in the Nepali context, for the infectious diseases of children in rural areas. So, we have to be very cautious about PPP as the solution. It shouldn’t be taken as the solution for the entire delivery of healthcare in a country like Nepal.
In its broader sense, public private partnership is a massive conglomeration of all sorts of arrangements and covering a wide spectrum of conditions. PPP is as broad as saying ‘general medicine’ within which there are all sorts of variations on the ways of doing things with their own idiosyncrasies, peculiarities and distortions.
(Based on a conversation with Chris Curry, a Clinical Associate Professor of Emergency Medicine at The University of Western Australia. He was in Nepal on invitation of the Nepal Medical Association to address the topic “Fostering partnerships in Heath”)
