THE state’s role in health and healthcare is as fundamental as health being a fundamental human right. The WHO, of which Pakistan has been a member since the beginning, says in its constitution: “Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.” Governments are the stew­ards of the health sector. Health policy­making; financing; human resource development; laying health infrastructure; disease surveillance for prevention and control; setting quality standards; regulation; health information; addressing the so­­cial and environmental determinants of heal­­th; and health service provision are some of the established and exclusive responsibilities of gov­ernments in the health sector. However, health service provision is not governments’ exclusive responsibility.

Due to a number of reasons, there is a growing trend in low- and middle-income countries to loop in the private health sector in service provision. Most governments in L&MICs have not really spent enough on healthcare. Resultantly, healthcare provision through the public sector has been both inadequate and of low quality. Another major reason is that, of whatever little is being spent on health by governments, a major part goes on tertiary healthcare; very little is spent on primary healthcare where the bulk of healthcare is needed, where disease can be prevented and managed at an early stage, and which is much more cost-effective. PHC is the foundation of universal health coverage (UHC).

As a result of the short supply of healthcare services by governments, a parallel private heal­­th sector has evolved purely as a function of mar­ket demand, and in many cases, induced demand. Provision of healthcare by private pro­viders is underpinned by established market failures in health, coupled with weak regulatory capacity. Nevertheless, due to a general demand inelasti­city in healthcare, the private health sector continues to grow and thrive. In Pakistan, for example, around 60 per cent of the total health expenditure is made by healthcare consumers in the private sector out of pocket. According to surveys, around 70pc of all outdoor health consultations take place in the private sector.

So, when governments are not able to provide sufficient healthcare of sufficient quality and when people buy services out of pocket from priv­ate providers, can the public and private health sectors join hands to improve access to and qua­lity of health services and serve the people bet­ter? This is the question which shapes different forms of public-private partnerships (PPPs) in health.

Health is too important a matter to be left to governments.

Before proceeding further, it is important to establish the private health sector’s non-mono­lithic nature. Diverse and vibrant, it is for-profit and not-for-profit. At some point, governments themselves start realising that they alone cannot do it. The idea of UHC, also as an SDG Goal 3 commitment, has reinforced the thinking that if all people have to be provided with essential healthcare, along with financial protection to those who cannot afford it, then governments on their own cannot advance UHC and have to engage the private health sector. The terms of engagement, however, make all the difference between different forms and shapes of PPPs.

I was walking in the beautiful building of a large tertiary-level hospital on the outskirts of Mu­­zaf­fargarh, a relatively poor district of south Punjab, with more than 50pc of its people living in multi­dimensional poverty. One of the adm­ini­s­trators was telling me that when Turkish leader Recep Tayyip Erdoan gifted this hospital to Pak­­istan, the then Punjab chief minister in 2014 handed it over to the Indus Hospital and Health Network (IHHN), a large and ever-gro­wing not-for-profit or­­ganisation, for its operatio­nal mana­gement. The Punjab government continues to pro­vide finances amounting to billions of rupees on a yearly basis. IHHN has full responsibility of managing the hos­pital, which provides quality healthcare completely free of cost to around 30,000 patients every month and has all the specialties. This is a great example of PPP in healthcare. IHHN is managing a number of such health facilities across the country.

ChildLife Foundation, another Pakistani not-for-profit, started in 2010 with revamping the children’s emergency room at Civil Hospital Karachi. By 2024, ChildLife has expanded to 313 government hospitals in all tehsils in Sindh, all districts in Balochistan, all DHQs and THQ hospitals in Punjab and three districts in Azad Kashmir, making emergency care for children accessible to 80pc of Pakistan’s population within 30 minutes. ChildLife is set to treat two million children annually in emergency rooms for public sector hospitals at no cost, with survival rates for critical cases quadrupling under their care. It is funded by government grants and philanthropic contributions — another great example of a PPP in healthcare at scale.

The Sehat Sahulat programme, which is state-financed health insurance currently only for hospitalisation, empanelled at one stage around 1,200 predominantly for-profit private sector hospitals across Pakistan. In this case, the government is purchasing predefined health services from private providers for its citizens. This is also a kind of PPP in which both sectors are engaging to serve the citizens better — especially those who cannot afford to pay.

There are other interfaces between the public and private sector for diagnostics, medicines, health technology, IT, public health programmes, including family planning, and others.

These and many other shades of PPPs in healthcare, in which both kinds of private health sectors are engaged with the public sector, are becoming ubiquitous not only in Pakistan but also many other L&MICs. This is the future of healthcare if these countries have to advance towards UHC in a sustainable manner.

Some may argue that this is absolving the state of its responsibility towards healthcare for the people. The counter argument is that PPPs are a means to strengthen quality healthcare and expand it to a maximum number of people through a stronger stewardship role for the state; more specifically, its contract management capacity. Done well, it can be a win-win solution.

In the coming articles, I will expand on this subject through examples and the potential of PPPs to help Pakistan redouble its pace towards UHC.

The writer is a former health minister, currently a professor of health systems & population health at Shifa Tameer-i-Millat University.

zedefar@gmail.com

Published in Dawn, September 20th, 2024