PPPs in India: Expansion without Evidence

This is the second post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we discuss the state of PPPs in the health sector, and the need for greater evidence on performance and enablers.

Since Government’s endorsement almost 15 years ago as a potential solution to deficient health service delivery, healthcare public-private partnerships (PPPs) have proliferated across India. They represent a rare form of public-private collaboration in a system dominated by private provision, but inhibited by considerable distrust between the two sectors. In effect, public-private engagement for service delivery in India’s health system hardly moves beyond the micro-level realm of PPP transactions. More recently, however, government-sponsored insurance schemes such as PM-JAY are purchasing insurance-related services from private third-party administrators and health services from private hospitals, and represent a bold step forward in public-private engagement. In this post, we focus on PPP models oriented toward expanding service delivery in which state health agencies contract private entities to build and operate facilities or manage services heretofore delivered through the public delivery system. Despite the proliferation of these transactions, little is known about their scope and impacts.

We began analyzing the state of healthcare PPPs in India about a year ago, and quickly found that the evidence-base is thin. In India, states are constitutionally responsible for publicly-financed health service delivery. Our analysis of multiple tender documents, newspaper articles, reports and websites of state PPP cells reveals that over the past decade, state governments across India have primarily focused on infrastructure PPPs. A growing number of states are experimenting with service delivery PPPs . Many of these involve the contracting out of select clinical and non-clinical services, such as diagnostic services (ex: Bihar, Himachal Pradesh) and dialysis services (ex: Delhi, Andhra Pradesh). Some states, such as Karnataka, Meghalaya and Arunachal Pradesh, have outsourced management of some primary care clinics to NGOs. To a lesser extent, states have or are experimenting with contracting out hospital management and service delivery (see examples here and here). Data on the actual number of ongoing PPPs is difficult to obtain or validate.

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The impact of these PPPs in terms of quality of care, costs and alignment with public priorities is largely unknown. Some diagnostic and dialysis PPPs have reported positive performance (see here and here), possibly because their narrow scope makes them relatively easier to design, tender, manage and monitor. One model that has widely been panned as a failure is the “land for beds model”, in which land is leased to a private partner to build and operate a hospital at little or no cost, in exchange for meeting specific conditions, usually including designating a share of beds to the poor. A troubled joint venture between the Delhi Government and Apollo Group exemplifies the challenges of this approach. Amazingly, this form of PPP remains under consideration in other states.

Anecdotal evidence suggests that some private operators faced insolvency in part due to late payments from government agencies. Further, while PPPs are often employed to fill gaps in access and quality that the public sector cannot address through its own resources, contracts often lack critical details: performance indicators, accountability frameworks and standard operating procedures are generally missing. As elsewhere, the public sector’s low capacity for contract management in India may be the Achilles heel of PPPs.

The lack of good quality information and data on specific healthcare PPPs in India is concerning. States across India are moving forward with this agenda (see here and here), and many interesting engagements are underway; yet there is little to no rigorous evaluation or even monitoring of these initiatives. Much of the evidence to date is drawn from “light touch” case studies that often appear promotional in nature. Little is known about impacts, lessons learned, and how starting conditions and government and contractor capacities contributed to performance.

As a result, states are left largely to operate in the dark, with limited knowledge of what has worked elsewhere in India, and why. The often ad hoc nature of PPP transactions leaves them vulnerable to repeat past failures, and unable to systematically learn from successes. More and better information and analysis are needed to inform state and national PPP policies so that governments can move this agenda forward in a more informed way. Until then, we can’t be sure why some PPPs succeed while others fail.

Check out other posts in this series below:

Let Managers Manage: Raising Indian Public Hospital Performance

Aceso Global CTO Contributes to WHO’s Vision on the Transformative Role of Hospitals in PHC

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The WHO recently released a brief on “The Transformative Role of Hospitals in the Future of Primary Health Care” as part of its Technical Series on Primary Healthcare. It builds on two documents, “People-Centred Hospitals towards Universal Health Coverage: a WHO Position Paper” and “A Global Vision for Person- and Community Centered Hospitals in a PHC-based Health System,” both of which are in press. Aceso Global CTO Gerard La Forgia participated as a technical expert to and contributing author of these foundational documents. 

The release of this brief is timely, reflecting a growing consensus in the global health community about the fundamental role of primary care in achieving person-centered universal health coverage (UHC), and the need to rethink traditional functions of hospitals to support this agenda.

Historically, hospital and primary care systems have operated in siloes, with hospitals isolated and primarily focused on what happens within their walls, and largely absent from preventive and promotive care. The resulting care model has been fragmented, inefficient, and curative in focus, often with an outsized share of services delivered by hospitals, due in part to the lack of integration across the health system. In low- and middle-income countries (LMICs), this has contributed to distorted costs and poor quality; these systems do not serve NCDs adequately, and recent health gains and longer lifespans are being jeopardized by their failures.

The WHO Expert Group brief envisions a future of primary healthcare in which hospitals break out of their walls and actively contribute to the development of comprehensive primary care, in partnership with primary care providers and communities. New roles for hospitals will be coupled with improved hospital organization and management to raise performance, supported by an enabling institutional and policy environment that facilitates needed change. The brief outlines this vision, and touches upon pathways to transformation. The forthcoming WHO position paper provides more specifics and will serve as a resource for policymakers and planners in LMICs.

Since its founding, Aceso Global has been at the forefront of this global movement calling for renewed thinking on the roles of hospitals in people-centered healthcare systems. CEO Maureen Lewis and CTO Gerard La Forgia were founding members of and led the Center for Global Development Hospitals for Health Working Group, and have been consistent voices highlighting the key role of hospitals in reaching UHC. Aceso Global has worked in numerous countries to strengthen hospital management, raise performance, and integrate inpatient and primary care. Most notably, we provided options for a hospital PPP in St. Lucia, led the production of a Vertical Integration/Network Diagnostic and Readiness Tool for the Joint Learning Network and advised a number of countries on hospital reform, among other efforts.

This WHO brief highlights the nexus in the hospital, primary care and UHC agendas, and represents an important step forward in the global movement toward better integrated, more responsive healthcare systems.

Public Hospital Autonomy: Global Experience

This presentation introduces hospital governance and management concepts related to autonomy. It covers the rationale for hospital autonomy, presents a framework for understanding different autonomy models, global cases involving autonomy reform and lessons learned. Some of the main lessons learned include: autonomy is often a prerequisite to improving management; autonomy requires strong accountability mechanisms; and managers must be empowered to respond to incentives set in autonomy agreements. Aceso Global CTO Gerard La Forgia delivered this presentation at the Hospital CEO forum in Manila, Philippines, organized by the Asian Development Bank, in July 2018.


Better Hospitals, Better Health Systems, Better Health

Despite their central role in healthcare delivery and their consumption of the lion’s share of national health budgets, hospitals in many emerging markets remain poorly governed, underfunded, and unevaluated. Hospitals have long been neglected by external stakeholders such as donors and multilateral institutions, and considered “black holes” by government ministries that fund facilities but provide limited governance or accountability. Historically, patients have borne the brunt of this negligence, shouldering high costs for poor quality of care.

This report proposes a Global Hospital Collaborative to transform the emerging market hospital landscape by promoting knowledge sharing, research, and cooperation between global experts and stakeholders in hospital governance, management, financing, and related fields. It was produced by the Hospitals for Health Working Group housed at the Center for Global Development, in collaboration with Aceso Global CEO Maureen Lewis and CTO Gerard La Forgia.

The proposed Collaborative would synthesize and centralize the vast but fragmented knowledge, research, and best practices related to hospital management and financing, as well as integration with the broader health system, and add to this knowledge base through additional research. The Collaborative is imagined as a forum for exchange that can lead to concrete improvements in health on the ground. Potential projects and products could include a web-based knowledge clearinghouse, conferences and webinars, data measurement and analysis, peer-to-peer learning exchanges, and in-country technical assistance. 


Case Studies: White Paper on Hospital Autonomy Potential in India

These case studies supplement Aceso Global’s White Paper on Hospital Autonomy Potential in India and assess hospital autonomy reforms in Brazil (Sao Paulo), Hong Kong, Vietnam, Portugal, Spain, the UK, and the US (NYC). Each case study introduces the country- or city-specific context leading to reforms, then details how the governance model functions in terms of operational and organizational autonomy, financial management, and accountability. Finally, each case study concludes with an analysis of the model’s strengths and weaknesses, and lessons learned. 



White Paper: Hospital Autonomy Potential in India

Public hospital autonomy reforms emerged out of frustration over poor hospital performance, citizen distrust of public care and evidence from other sectors of the benefits of delivery models that incorporate or build on private sector incentives. Hierarchical bureaucracy, limited managerial decision-making authority and nonexistent accountability have resulted in poorly performing hospitals, and driven the search for alternative models of health care delivery.

This paper takes up three major organizational forms of hospital autonomy reforms – autonomization, corporatization, and public-private partnerships – and the underlying components necessary for their successful implementation. International examples of hospital autonomy reforms in both OECD and emerging market countries serve as a foundation for analyzing potential opportunities, as well as pitfalls, of autonomy reforms in different contexts.

The paper concludes with an evaluation of the possible application of public hospital autonomy reforms in India. A brief overview of existing autonomy reforms in non-hospital settings is followed by recommendations for the Indian government on the applicability of specific models to the Indian public health sector.

Please contact us for access to this product. 

Pay for Performance and Hospital Quality Within the Affordable Care Act

This presentation examines the new generation of Pay for Performance initiatives included in the U.S. Affordable Care Act (ACA) and provides lessons for countries considering similar health care payment reforms. It lists measures and outcomes used to gauge performance under the ACA, and the payment schemes employed to link pay to these measures. While highlighting various improvements arising from the adoption of Pay for Performance, such as lower costs and reduced readmission rates, the presentation also discusses emerging challenges.

Please contact us for access to this product. 

Patient Flow Analysis: Innovation for OECD & Emerging Market Hospitals

This presentation provides a basic introduction to Patient Flow Analysis (PFA) and its applications and relevance to hospitals in emerging markets. Specific international examples highlight the benefits of PFA for hospitals, including increased patient and staff satisfaction, greater patient throughput, reduced costs, and less chaotic hospital environments. The presentation concludes with an overview of Aceso Global’s ongoing work in Mexico on this topic, including specific metrics and measures used to perform PFA, and potential challenges that can arise when attempting to implement patient flow management changes. 

Please contact us for access to this product. 

Hospitals Are Key to Reaching Universal Health Coverage

The global commitment to universal health coverage (UHC)—target 3.8 of the Global Goals for Sustainable Development—is as ambitious as it is energizing. Ensuring that everyone, everywhere has access to quality health care without being forced into poverty will require stronger health systems that generate better patient services and improve patient health. To that end, investments in hospitals and their performance will be key.

UHC is about timely, appropriate, and high quality services available at an affordable price. Yet, in striving towards this aim, hospitals are often overlooked by governments and donors alike. This needs to change given the shift in disease burden, whereby cardiovascular disease, cancer, and trauma, rather than infectious diseases, now dominate the burden of disease even in the poorest countries. Cancer and cardiovascular disease each claim more lives in Sub-Saharan Africa than AIDS, tuberculosis and malaria combined—although the latter remain the focus of funders. Health investment priorities must shift to meet these changing disease profiles.

If we continue to give little attention to upgrading and integrating hospitals and their services, low- and middle-income countries will remain ill-equipped to meet their commitment to UHC. Sticking with the status quo leaves modernization and expansion of hospitals to the private sector, which typically skews investments towards the upper and middle classes and often increases inequalities within and across countries. For example, the boom in private hospital construction in many middle-income countries in East Asia compensates for the lack of public investment in hospital services. However, these private hospitals are used by the wealthy who can afford their services while the poor are relegated to seek care at public hospitals. The poorest citizens in low- and middle-income countries ultimately suffer the most.

Although bilateral and multilateral donors focus almost exclusively on primary health care to meet UHC goals, and philanthropic institutions like the Bill & Melinda Gates Foundation have followed suit, this strategy falls short of the needs and preferences of country governments and their citizens. And it undermines the quality of the evolving health care system.  

First, countries are clearly concerned by the lack of hospital investments. This is most evident in how countries are increasingly seeking support from the multilateral development banks and their private sector arms, such as the International Finance Corporation, to make new investments.

Middle-income countries moving towards UHC, such as China, Brazil and Nigeria, already spend 70 percent of their health budgets on hospital care. Improving hospitals’ efficiency and quality, as well as integrating with primary care, is critical to raising performance. It would also be cost effective. Without hospitals, primary health care services lack a point of reference and an effective referral network. If hospitals are dysfunctional, services at all levels suffer.

Second, the specialized expertise and support of hospital care remains central to the treatment of trauma, cancer, and other chronic diseases, which require new and more costly health care strategies. Although primary health care remains important, building integrated care networks that link hospitals to outpatient services can offer critical and cost effective services to the people who increasingly depend on them.

As countries and donors seek to manage the rise of chronic and non-communicable diseases, prioritizing the building of health system capacity and improving health system performance can bring healthy returns. As I’ve written about before, this means renewing their efforts to upgrade health care systems, investing in secondary and tertiary facilities, and integrating care across inpatient and outpatient services. Furthermore, investments should be made to improve hospital leadership, which is an indispensable tenet of quality hospitals, management, and health care.

Without putting efforts towards hospitals, UHC goals risk becoming a hollow exhortation rather than empowering targets. That’s why I’m helping host an event at the CGD on December 7 to launch a new report, Better Hospitals, Better Health Systems, Better Health. I hope you’ll join us for a discussion on the critical issues around, and importance of, improving and reforming health systems and hospitals in low- and middle-income countries, where it’s needed most. (Register here)

Global Insights Series: The Role of Healthcare Accreditation in Mexico

This is the first in a series of interviews with global experts on approaches to specific health challenges.

Sebastian Garcia Saiso, the General Director of Quality and Education in Health at the Mexican Ministry of Health, discusses the role of accreditation in Mexico with CEO Maureen Lewis at the International Foundation for Integrated Care Conference.

The Ministry of Health has an active accreditation process for healthcare providers that complements other initiatives aimed at raising quality and ensuring basic standards of care. The accreditation body’s enforcement has led to the sanctioning of hospitals and hospital departments. These facilities or departments are ineligible to receive public funding until their deficiencies are resolved. Dr. Saiso gives a comprehensive background to the accreditation policy in Mexico, explains the government role in accrediting both public and private hospitals, discusses quality of health and integrated care, and gives his views on enforcement.



ML (Maureen Lewis): Can you discuss the accreditation process for hospitals in Mexico, how it works, how you see this connecting to quality of care, and its importance in terms of healthcare delivery in the country?


SG (Sebastian Garcia Saiso): I am going to go slightly before that, before accreditation, because it’s important to understand where policy comes from. The health system in Mexico was officially established in 1943 with the creation of the social security system, and it has had several milestones along the way from 1943 to the moment.


The provision of services before 1983 was done through social security as a mechanism directly linked to labor. And it was in 1983 that we in Mexico changed the constitution, which reflected the right of health protection as a constitutional right, which later became a human right as established by the constitution. This is also linked to the decentralization of services in the ‘80s and ‘90s – all those services provided outside social security, provided by a network of providers at the national context, were given autonomy to each of the 32 states of the Mexican republic and that created a system comprised by social security on one side and 32 autonomous providers on the other side for those not enrolled in social security.


By 2000, there was a very important milestone in which Mexico carried out a study and detected that 50% of the population did not have access to a formal form of financing for health needs – meaning 50 million people did not have access to social security because of their labor status. That created a gap and inequities in different kinds of population.

In 2003, there was a very important reform pushed forward to establish Seguro Popular – it’s a financing mechanism based on general taxation for all those not enrolled in social security.  Parallel to that reform, the accreditation system was established to guarantee Seguro Popular enrollees the minimum standards in terms of quality and capacity at the local level. This was set up as a strategy acknowledging that there was a very important difference across the 32 different state providers and that the financing from the federation was going to be generally the same, meaning the federation was going to pay for services in all the states.


In 2004, we started the accreditation process. It was a very important challenge to start accrediting for a financing mechanism that was already in place. So there was a huge rush to accredit establishments so that we could have units providing services to match the financing that became available. What’s happened since then is that we have about 12,000 medical units accredited within the Seguro Popular financing mechanism. It becomes a need to evaluate what has happened with this accreditation mechanism and to set forward new regulatory mechanisms so we make sure that this surveillance mechanism, which will ensure the minimum standards of quality and safety are in place not just across Segura Popular but also across different services, including social security.


So this is one of our main concerns at the moment in which we have managed to balance or reduce the gaps in financing between different populations with a particular set of providers and those outside the public financing mechanism, which includes the private providers.


Thinking of this is a very comprehensive and ambitious reform that would set up a horizontal as much as a regulatory mechanism in which accreditation would be one mechanism to ensure minimum standards. This means making sure that through accreditation and surveillance mechanisms that standards are met, but then also measuring how performance changes with these mechanisms so that we make sure that those who are not performing as well can have incentives also to move into this direction. So, by accrediting, you make sure that no one below this standard exists in a market of provision, and then later, through incentives, you actually make innovation and promote change towards where the system should be.


In a context like Mexico in which the demographic and epidemiological transition is such an important role in what healthcare delivery will be in the next few years, you need to have very small mechanisms to steer the system in that direction. Accreditation is one of the tools you have in the regulatory framework, and then you have to create different incentives and different mechanisms to promote it.


ML: I am also wondering – are you responsible for accrediting all public and private across the board?


SG: We are responsible at the General Directorate to accredit establishments across all different providers, but only when they are linked to the financing mechanism provided by Seguro Popular. If we have interventions provided by social security, we would accredit them – such as maternal emergency care, where regardless of the insurer we provide services across the spectrum and that is accredited by us. We have accredited private providers that are part of a local network of services especially for those services under the fund for catastrophic expenditure protections which includes the most expensive and specialized interventions within Seguro Popular and, of course, those public providers owned by the state which are the main provisions under Seguro Popular financing.


ML: Because we have been talking about integrated care, how do you see the regulations and accreditation trying to play a role in promoting integrated care going forward?


SG: Quality of healthcare is a very important part of integrated care. You may have many of the other aspects defined as components of integrated care, but if you do not have a strong quality framework, its very hard to achieve this interaction between different areas of healthcare, and different mechanisms to achieve a patient centered health policy. So regulation is one of these areas that we can use to steer the system.


We are working with other governments – here I prefer the experience that France has developed on tracing patients to ensure that healthcare is provided in a continuous manner. That is something that we are incorporating in our accreditation system to make sure that we follow patients at different levels to make sure that care is provided when the patient requires it at the type of facility which is ideal for this and by a group of people that is required to treat this condition.


So this means, for example, in care for pediatrics of quality, the patient is diagnosed properly in primary care, but it refers also to units that have the resources to actually treat the condition so we have problems for example in rural communities in which patients may delay a very long time before they are diagnosed and referred to a higher level of care, and this creates an opportunity cost which is sometimes very important in trying to achieve better outcomes in healthcare.


ML: What about enforcement of accreditation and the accountability that comes within it - how does that work, and how do you manage that within the regulatory system?


SG: It is something vital to any system, and it has to be constant. You have to always work on accountability of any system and any tool that you have to actually reach results. This is the case of accreditation and regulation in general in which you can never lose sight of what you are trying to achieve, and you have to work towards that all the time. The case in Mexico is very important, with as you have seen a few minutes ago, we evaluated the number of units that provide pediatric care and we find a great range of performance results in these units. That creates concern whether accreditation is actually achieving its purpose, meaning greater homogeneity in the provision of services.


What we are trying to do now - and it’s a great step forward in our accreditation policy - is that we are trying to evaluate risk, by measuring performance in each of the units that are accredited, and then creating a mechanism to survey those that are actually show a greater risk of not showing results and help them. One would be if they have lost the accreditation standards to push them to achieve them again without actually creating a risk to the patient. The other one would be to incentivize that they not only maintain these standards but also improve them so that we can raise the standard across the entire system. This creates a moving forward policy in which you don’t only make sure they have the minimum at this moment but you also follow them and evaluate them periodically so that you move the standard slightly upwards every once in a while.


ML: Is there anything else you want to add?


SG: I want to make sure that the point gets across that regulation is only one of the things that the system has to contain. It’s only one thing; there are no silver bullets in any health system. It’s such a complex array of circumstances, actors, and mechanisms that have to interact and move in the same direction, that regulation is only one way to equalize to make sure that everyone knows their role, at their time, and towards a particular goal.






Hospitals in Low- and Middle-Income Countries: What Do We Know?

The product reviews hospital research in emerging markets and developing countries, discusses how health care delivery and hospital care are changing, examines ways to capture efficiency and quality of care, including using the World Management Survey, and evaluates implications for the future of health in emerging markets and developing countries.

Please contact us for access to this product.

Hospital Performance in Brazil: The Search for Excellence

This book combines a comprehensive overview of the Brazilian hospital sector with in-depth analyses of the key elements of interest in promoting and ensuring excellence in hospital performance. The book offers specific recommendations that go to the heart of the problem, weighing in context on implementation and specifically highlighting the need to strengthen governance arrangements, improve accountability, and sharpen resource management.

La Forgia, G. and B. Couttolenc. 2008. Hospital Performance in Brazil: The Search for Excellence. Washington, DC: World Bank.

 (published in English and Portuguese)



Hospitals and Public Health Priorities: Role of Policy

This product examines the shifting landscape of health care in developing countries, discusses evolving public and private sector roles, places them in the context of Foreign Direct Investment (FDI), evaluates how government roles are shifting away, and discusses the future for hospitals and hospital networks.

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Better Hospitals, Better Health Systems: Urgency of the Hospital Agenda

As the global community shifts to meet the challenge of universal healthcare (UHC), the new priorities and imperatives facing emerging economies will require attention and investment. Climbing costs, rapid escalation of chronic diseases, emergence of complex morbidities and poly-morbidities, relentless urbanization, and expanding expectations of citizens are simultaneously confronting countries as they move towards UHC. Responding effectively to the UHC challenges will entail strengthening health systems to generate better patient services and improved population outcomes. Investing in hospitals and their performance will be key to this success.

Reaching the expectations of universal health coverage requires renewed efforts to upgrade and strengthen hospital investments, and to promote the integration of patient care across levels of care. Whether addressing Ebola outbreaks, promoting maternal and infant survival, managing the burgeoning chronic disease epidemic, or simply meeting the ICU and surgery commitments of healthcare, hospitals remain central. The lack of investment and modernization of hospitals over the past few decades—whether in physical plant infrastructure or management systems—has rendered many expensive inpatient institutions shells of their potential.

This paper outlines the nature of the issues surrounding hospitals in emerging markets, making the case for early action to bridge the abyss of neglected hospital investments and the path needed to address the shortcomings and gaps in current policies and investments.