Public–Private Partnership Model in Delivering Quality Health Care and Medical Education - An Enduring Success Story for the Past Seven Decades

Abstract

Public–private partnerships (PPPs) are integral to the National Health Mission (NHM). Kasturba Medical College (KMC), Mangalore, was the first private institution in India to embrace the PPP model way back in 1953. The then Government of Madras permitted KMC Mangalore to partner with the 2 district hospitals – the Government Wenlock and the Lady Goschen Hospitals. For almost seven decades, KMC Mangalore has been using the clinical facilities at District Wenlock and Lady Goschen hospitals to provide quality health care and also train the Undergraduate and Postgraduate students of KMC. The Manipal experiment is a shining example of public–private collaboration to provide quality accessible health care to everyone, which is in line with the Sustainable Development Goal (SDG) 3 and its targets.

BACKGROUND

Health care in India is not only one of the largest but also the fast-growing sectors both in terms of manpower and economy. The healthcare delivery system in India is a complex interaction between two major components – the public sector and the dominant private sector, which has seen an exponential growth in the past two decades.[1]

Recommendations of the Bhore Committee in 1946 led to the establishment of a three-tiered public health care system in India, aimed at providing accessible preventive, promotive, and curative services to both the rural and urban population irrespective of their socioeconomic status.[2]

The subsequent policies, built on the recommendations of the Bhore committee, emphasized the delivery and utilization of public health services through decentralization and increased expenditure on health. However, the public health care system failed to provide quality health care to a majority of rural population, as only the Primary Health Care (PHC) centers were established in rural areas and most of the secondary and tertiary care institutions were established in urban areas.[3,4] This allowed the private health care sector to expand rapidly and provide healthcare services, even to the rural population.[5] Though both healthcare systems functioned independently, there have been instances of informal interactions between the two systems. These collaborations were limited to either capacity building of the health system and/or mobilization of resources.[4]

The term “public–private partnership” (PPP) gained popularity during the global health reforms in the 90s with various international and intercountry organizations partnering with global health institutions in low- and middle-income countries.[2]

The National Health Policy of 2017 emphasizes the partnership with the private sector in the provision of curative, diagnostic, rehabilitative, palliative care services, mental health, and telemedicine.[4] Currently, PPPs are one of the mainstays of health reforms in India and continue to be an integral part of the National Health Mission (NHM).[4]

PPP models in Health Care: Governments have worked with the private sector to provide services through PPPs in the healthcare industry to fulfill one or more of the following:

• Finance - Bankrolling the project, either partially or completely.

• Design - Designing the project, including the layout of facilities and method of providing healthcare services.

• Build - Constructing or renovating the facilities included in the project.

• Maintain - Maintenance of project set-up which includes facilities and equipment.

• Operate - Provision of necessary tools, IT support, and administration of nonclinical services.

• Deliver - Provision and administration of healthcare and clinical support services.

Most facility-based PPPs combine these features into one of three models:

• Infrastructure-based model - To construct or upgrade public healthcare facilities.

• Discrete Clinical Services model - To provide new services or expand the existing service delivery capacity.

• Integrated PPP model - To offer a complete package of services, including infrastructure development and delivery of health care services.[6]

THE SUCCESS OF THE PPP MODEL IN INDIAN HEALTHCARE

Effective partnership between public and private sector is essential for realizing the goal of affordable universal health coverage.[7]

COVID-19 pandemic has demonstrated how PPPs could address both the challenges of affordability and accessibility, especially in rural areas. The pandemic catalyzed both the public and private sectors, resulting in unprecedented partnerships in diagnostics, technology, and life-saving treatments.

PPP can also address the shortage of health care manpower and immensely contribute in capacity building of doctors, nurses, and paramedics. India currently has a doctor population ratio of 1:1445, which is far below the WHO prescribed norm of 1:1000, and majority of these doctors are concentrated in urban areas.[8] Thus, PPPs can immensely contribute toward increasing the doctor–population ratio in rural areas and bridge the gap in health care services that exists between urban and rural areas.[9]

The PPP model need not be restricted to organizations only; at the community level, the practitioners (family physicians and specialists) can be involved in extending health care services to the needy at the Govt. Hospitals. This will ensure quality health care to the needy rural populations. The PPP model in healthcare can also extend to the presence of doctors in local bodies or government institutions.[10] In some cases, local governments, or municipalities partner with private healthcare providers to enhance healthcare services at the community level. Under such partnerships, private doctors or medical professionals may be engaged to work in local health centers, clinics, or hospitals that are managed or supported by the government. This collaboration can help improve healthcare access, especially in underserved areas, by leveraging the expertise and resources of private practitioners.[10]

The private medical colleges providing health services to the population through the Urban and Rural Health Training Centers under auspice of the Department of Community Medicine is another example for this. The recent National Medical Council (NMC) mandated Family Adoption Program (FAP) and District Residency Program (DRP) is a step toward providing health care services to far and needy.[11,12] Thus, PPP model will be an effective strategy in providing health services to rural areas in India.

The involvement of private healthcare providers can complement the efforts of the public sector in delivering quality healthcare services to rural populations.[10] To reiterate, the private institutions by providing manpower, material resources, and quality health care services through the PPP model can contribute immensely as well as supplement the government’s efforts of providing universal health care which is accessible and affordable.

PUBLIC–PRIVATE PARTNERSHIP: THE MANIPAL MODEL

Kasturba Medical College (KMC), Mangalore, was the first private self-financing institution in India to propose, engage, and successfully deliver definitive results through the PPP model since 1955, as envisioned by the visionary founder Late Dr. T.M.A. Pai. This was at a time when the very terminology of PPP was unheard off in the country. It was initiated on a simple and straightforward premise that every citizen has an obligation to proactively assist the public institutions for the larger good of the nation in all such situations where the public enterprise proves wanting and lacking.[13]

The concept of a medical college by private effort with the aid of existing public institutions was unheard of in those days. Undeterred, this novel concept was given a try. The then Government of Madras, under this PPP model, permitted KMC Mangalore to partner with the 2 district hospitals namely – the Government Wenlock and Lady Goschen Hospitals. Now for almost seven decades, KMC Mangalore has been using the clinical facilities at District Wenlock and Lady Goschen hospitals to provide quality healthcare services and also to train the undergraduate and postgraduate medical students of KMC.[14]

Listed among the oldest hospitals in Karnataka, Government District Wenlock Hospital (GDWH) and Lady Goschen Hospital (LGH) have a proud heritage that dates back to more than 150 years. Leading Scientists including Sir Ronald Ross and Dr Charles Donovan have worked at Government District Wenlock Hospital before making pivotal discoveries that have altered the practice of medicine. Both hospitals not only cater to the health care needs of the Dakshina Kannada district but also function as a tertiary care referral facility and receives patients from 8 neighbouring districts of Karnataka and also the neighbouring State of Kerala. Commissioned in 1953, the first batch of MBBS students gave an impressive account of themselves in December 1957 by a pass percentage which was much higher than the national average at that time. The summative examination was observed by a team of experts led by Dr S Patrao and he praised the students and the teachers.[15]

In 1965, the General Medical Council of Great Britain visited the college. The visiting team headed by Sir T N A Jeffcoate granted GMC recognition to the college. Scores of students have come out of this highly successful PPP model which has stood the test of time for seven decades and is growing stronger. The first ever postgraduate program in the erstwhile state of Mysore was started in this PPP (General Surgery in 1960). The PPP was also responsible for the first successful open-heart surgery in Wenlock hospital. The Manipal experiment is a shining example of what collaboration between public and private sectors can achieve!

These two government hospitals are now leading the way in providing high-quality patient care that meets the community’s requirements because of this partnership. The college offers the services of consultants, covering the full cost of laboratory tests, employing nurses, technicians, and office staff, taking over housekeeping and security duties, networking various departments and managing hospital computerization, maintaining, and servicing medical equipment, computerizing the medical records, and setting up a separate clinical lab at Wenlock Hospital. In turn, the institution uses the hospitals for training undergraduate (MBBS) and postgraduate (MD/MS) medical students.

COMPONENTS OF MANIPAL PPP MODEL

1. Maintaining the infrastructure.

2. Public: The Department of Health and Family Welfare, Government of Karnataka, is responsible for the administration of the hospital. District Medical Officer/District Surgeon is appointed to oversee the administrative duties. Consumables and equipments are procured by the administration.

3. Private: Clinical services, routine patient care, housekeeping, and security are the responsibilities of Kasturba Medical College, Mangalore.

   • Provision of clinical fees, and more than 100 Specialists and Consultants including Super-specialists

   • Paramedical staff (additional nurses, technicians, and clerical staff)

   • Renovation and upgradation of infrastructure.

   • Establishment of the clinical lab and cath lab in Wenlock hospital.

   • Free laboratory services from NABL accredited central lab to all patients admitted to the hospital.

   • Networking of various departments.

   • Computerization of the hospital including the Medical Records Department.

   • Servicing and maintenance of medical equipment [Figure 1].

Figure 1.

Public–private partnership - The Manipal Model

BENEFITS TO THE GOVERNMENT (EXCHEQUER)

Less expenditure on salary, high-quality patient care, and improvement in professional knowledge.

Training of medical students will address the dearth of doctors in India.

BENEFITS TO MEDICAL EDUCATION AND TRAINING

The medical college gets access to clinical teaching materials for training medical students. Provision of high-quality patient care ensures an increased influx of patients for clinical training of medical students.

BENEFITS TO THE COMMUNITY (PUBLIC)

The PPP model has ensured that the all the members of the community have access to quality health services. With over 1000 beds and an average bed occupancy rate of 90%, it is a testament to the standard of care provided in these government hospitals. The hospitals OPD also handle an average of 3000 patients per day, every patient being consulted, and examined by specialists and super-specialists.

The public also gets access to state-of-the-art diagnostic and treatment modalities which are offered free of cost to the patients.

The poverty–illness–poverty cycle could be broken by using this model since patients get access to high-quality services at public hospitals at an affordable price. This partnership between the government hospitals and the Kasturba Medical College has resulted in the provision of quality health services to the people of the district.[14,16]

CHALLENGES ENCOUNTERED IN THE PPP MODEL

Public–private organizations (PPPs) in healthcare can offer various benefits, but they too come with a few challenges, particularly for the private sector.

Some of the few key challenges confronted by the private sectors in PPPs in healthcare include:

1. Regulatory and Policy Challenges:[17]

   Frequent change in government policies along with complex administrative processes and bureaucratic red tape can pose a serious threat to the private stakeholder who might be discouraged from long term investment in the partnership.

2. Financial Risks:

   Lack of lucrative financial incentives along with delays or inconsistencies in government funding and subsidies can affect the financial stability of the PPP.

3. Operational Challenges:

   Integrating private sector services with public health systems is a challenging process, which if not monitored can result in compromise of quality of the service provided. Integrating advanced technologies and ensuring interoperability between public and private systems can be complex. Developing and maintaining healthcare infrastructure can be resource-intensive and challenging. Frequent training and capacity building of the human resources may be required which might not be financially feasible at times.

4. Contractual and legal issues:

   Sorting out any legal and contractual issues arising out of PPP may be time consuming and costly.

5. Public Perception and Trust:

   Gaining and maintaining public trust in private sector involvement in healthcare can be difficult. Overall, these challenges should be closely scrutinized by the private sectors and then develop substantial strategies to handle them during PPP model in healthcare implementation.

CONCLUSIONS

PPPs in the health sector can be an effective strategy to address the deficiencies of both sectors. By combining public sector oversight and private sector expertise, PPPs can provide effective and quality health services for the benefit of the community. Key characteristics of the PPP model should be long-term contracts, risk allocation, performance indicators, and government ownership of assets.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.