DEFINING PUBLIC PRIVATE PARTNERSHIP IN HEALTH

Public-Private Partnership or PPP in the context of the health sector is an instrument for
improving the health of the population. PPP is to be seen in the context of viewing the whole
medical sector as a national asset with health promotion as goal of all health providers, private or
public. The Private and Non-profit sectors are also very much accountable to overall health
systems and services of the country. Therefore, synergies where all the stakeholders feel they
are part of the system and do everything possible to strengthen national policies and programmes
needs to be emphasized with a proactive role from the Government.

However for definitional purpose, “Public” would define Government or organizations

functioning under State budgets, “Private” would be the Profit/Non-profit/Voluntary sector and
“Partnership” would mean a collaborative effort and reciprocal relationship between two parties
with clear terms and conditions to achieve mutually understood and agreed upon objectives
following certain mechanisms.
PPP however would not mean privatization of the health sector. Partnership is not meant
to be a substitution for lesser provisioning of government resources nor an abdication of
Government responsibility but as a tool for augmenting the public health system.

THE ROLE OF THE PRIVATE SECTOR IN HEALTH CARE

Utilisation of Hospital Services

8,000

7,000

6,000

5,000
Private
4,000 Public
3,000

2,000

1,000

-
a
r t
G har

h y Ke k a
M Pra l a

Ta aja b
N r a sh

l
O ast
t h ra

P u sa

U mi tan

W Pra d u
Bi sh

en h
a c H jura

ga
r n e sh
l P yan

R nja

t B es
ra

or st
a

ah de

ri s
e

a
E

s
at
ad

es d
tta l N
u

Ka ad
a

a
Pr

r
ra

he
dh

ad
An

im

M
H

Source Pearson M, Impact and Expenditure Review, Part II Policy issues. DFID, 2002

Over the years the private health sector in India has grown markedly. Today the private
sector provides 58% of the hospitals, 29% of the beds in the hospitals and 81% of the doctors.
(The Report of the Task Force on Medical Education, MoHFW)
The private providers in treatment of illness are 78% in the rural areas and 81% in the
urban areas. The use of public health care is lowest in the states of Bihar and Uttar Pradesh. The
reliance on the private sector is highest in Bihar. 77% of OPD cases in rural areas and 80% in
urban areas are being serviced by the private sector in the country. (60th round of the National
Sample Survey Organisation (NSSO) Report.

3
 The success of health care in Tamil Nadu and Kerala is not only on account of the Public
Health System. The private sector has also provided useful contribution in improving health care
provision.

Studies of the operations of successful field NGOs have shown that they have produced
dramatic results through primary sector health care services at costs ranging from Rs. 21 to Rs.
91 per capita per year. Though such pilot projects are not directly upscalable, they demonstrate
promising possibilities of meeting the health needs of the citizens by focused thrust on primary
healthcare services. (NSSO 60th Round)

India: Percentage of Hospitalizations In The Public and Private

Sector Among Those Below The Poverty Line, According To State

100%
Percentage

80%
60%
40%
20%
0%
A
H

LA

A
R

H
T

N
AB

SH
SH

U
RA

AS
AN
ES

AK

TR
HA

ES

HA
ISS

AD
RA

DE
DE

NJ
AD

SH

HE
AD
JA

RY

AT
BI

ST

LN
OR

PU
KE

RA
RA
GU

RA

JA
PR

RN
HA

PR

RT

MI

RP
LP

RA
HA
KA

TA
NO
RA

YA
HA

TA
MA
DH
DH

UT
AC

MA
AN

HIM

States

Public Facilities Private Facilities

Source Pearson M, Impact and Expenditure Review, Part II Policy issues. DFID,2002

While data and information is still being collated, the private health sector seems to be the
most unregulated sector in India. The quantum of health services the private sector provides is
large but is of poor and uneven quality. Services, particularly in the private sector have shown a
trend towards high cost, high tech procedures and regimens. Another relevant aspect borne out
by several field studies is that private health services are significantly more expensive than public
health services – in a series of studies, outpatient services have been found to be 20-54% higher
and inpatient services 107-740% higher. (Report of the Task Force on Medical Education,
MoHFW.

Widely perceived to be inequitable, expensive, over indulgent in clinical procedures, and

without standards of quality, the private sector is also seen to be easily accessible, better
managed and more efficient than its public counterpart.

4
 Given the overwhelming presence of private sector in health, there is a need to regulate and
involve the private sector in an appropriate public-private mix for providing comprehensive and
universal primary health care to all. However there is an overwhelming need for action on
privatization of health services, so that the health care does not become a commodity for buying
and selling in the market but remains a public good, which is so very important for India where
1/3 of the population can hardly access amenities of life, leave alone health care.

In view of the non-availability of quality care at a reasonable cost from the private sector ,
the upscaling of non-profit sector in health care both Primary, Secondary and Tertiary care,
particularly with the growing problems of chronic diseases and diseases like HIV/AIDS, needs
long term care and support.

OBJECTIVES OF PUBLIC PRIVATE PARTNERSHIPS

Universal coverage and equity for primary health care should be the main objective of any
PPP mechanism besides:
¾ Improving quality, accessibility, availability, acceptability and efficiency
¾ Exchange of skills and expertise between the public and private sector
¾ Mobilization of additional resources.
¾ Improve the efficiency in allocation of resources and additional resource generation
¾ Strengthening the existing health system by improving the management of health within
the government infrastructure
¾ Widening the range of services and number of services providers.
¾ Clearly defined sharing of risks
¾ Community ownership

REVIEW OF EXISTING SCENARIO OF PPP

POLICY PRESCRIPTION

Public-Private Partnership has emerged as one of the options to influence the growth of
private sector with public goals in mind. Under the Tenth Five Year Plan (2002-2007), initiatives
have been taken to define the role of the government, private and voluntary organizations in
meeting the growing needs for health care services including RCH and other national health
programmes. The Mid Term Appraisal of the Tenth Five Year Plan also advocates for
partnerships subject to suitability at the primary, secondary and tertiary levels. 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. The policy also wanted the
participation of the non-governmental sector in the national disease control programmes so as to
ensure that standard treatment protocols are followed. The Ministry of Health and Family Welfare,
Government of India, has also evolved guidelines for public-private partnership in different
National Health Programmes like RNTCP, NBCP, NLEP, RCH, etc. However, States have varied
experiences of implementation and success of these initiatives. Under the Reproductive and
Child Health Programme Phase II (2005-2009), several initiatives have been proposed to
strengthen social-franchising initiatives. National Rural Health Mission (NRHM 2005-2012)
recently launched by the Hon’ble Prime Minister of India 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. In order to
tap the resources available in the private sector and to conceptualize the strategies, Government
of India has constituted a Technical Advisory Group for this purpose, consisting of officials of
GOI, development partners and other stakeholders. The Task Group is in the process of finalizing
its recommendation.

5
REVIEW OF PPP IN THE HEALTH SECTOR
During the last few years, the Centre as well as the State Governments have initiated a wide
variety of public-private partnership arrangements to meet the growing health care needs of the
population under five basic mechanisms in the health sector:
¾ Contracting in-government hires individual on a temporary basis to provide services
¾ Contracting out- government pays outside individual to mange a specific function
¾ Subsidies-government gives funds to private groups to provide specific services
¾ Leasing or rentals-government offers the use of its facilities to a private organization
¾ Privatization-government gives or sells a public health facility to a private group

An attempt has been made here to encapsulate some of the on-going initiatives in public
private partnerships in selected states.

A. Partnership between the Government and the for profit sector

1. Contracting in Sawai Man Singh Hospital, Jaipur

• The SMS hospital has established a Life Line Fluid Drug Store to contract out low cost
high quality medicine and surgical items on a 24-hour basis inside the hospital. The agency
to operate the drug store is selected through bidding. The successful bidder is a proprietary
agency, and the medical superintendent is the overall supervisor in charge of monitoring the
store and it’s functioning. The contractor appoints and manages the remuneration of the staff
from the sales receipts. The SMS hospital shares resources with the drug store such as
electricity; water; computers for daily operations; physical space; stationery and medicines.
The contractor provides all staff salaries; daily operations and distribution of medicine;
maintenance of records and monthly reports to SMS Hospital. The SMS Hospital provides all
medicines to the drug store, and the contractor has no power to purchase or sell medicines
himself. The contractor gains substantial profits, could expand his contacts and gain
popularity through LLFS. However, the contractor has to abide by all the rules and
regulations as given in the contract document.
• The SMS Hospital has also contracted out the installation, operation and maintenance of
CT-scan and MRI services to a private agency. The agency is paid a monthly rent by the
hospital and the agency has to render free services to 20% of the patients belonging to the
poor socio-economic categories

2. The Uttaranchal Mobile Hospital and Research Center (UMHRC) is three-way partnership
among the Technology Information, Forecasting and Assessment Council (TIFAC), the
Government of Uttaranchal and the Birla Institute of Scientific Research (BISR). The motive
behind the partnership was to provide health care and diagnostic facilities to poor and rural
people at their doorstep in the difficult hilly terrains. TIFAC and the State Govt. shares the funds
sanctioned to BISR on an equal basis.

3. Contracting out of IEC services to the private sector by the State Malaria Control Society in
Gujarat is underway in order to control malaria in the state. The IEC budget from various
pharmaceutical companies is pooled together on a common basis and the agencies hired by the
private sector are allocated the money for development of IEC material through a special
sanction.

4. Contracting in of services like cleaning and maintenance of buildings, security, waste

management, scavenging, laundry, diet, etc. to the private sector has been tried in states like
Himachal Pradesh; Karnataka; Orissa (cleaning work of Capital Hospital by Sulabh International);
Punjab; Tripura (contracting Sulabh International for upkeep, cleaning and maintenance of the
G.B. Hospital and the surrounding area); Uttaranchal, etc.

5. The Government of Andhra Pradesh has initiated the Arogya Raksha Scheme in collaboration
with the New India Assurance Company and with private clinics. It is an insurance scheme fully

6
funded by the government. It provides hospitalization benefits and personal accident benefits to
citizens below the poverty line who undergo sterilization for family planning from government
health institutions. The government paid an insurance premium of Rs. 75 per family to the
insurance company, with the expected enrollment of 200,000 acceptors in the first year.

The medical officer in the clinics issues a Arogya Raksha Certificate to the person who
undergoes sterilization. The person and two of her/his children below the age of five years are
covered under the hospitalization benefit and personal accident benefit schemes. The person
and/oor her/his children could get in-patient treatment in the hospital upto a maximum of Rs. 2000
per hospitalization, and subject to a limit of Rs. 4000 for all treatments taken under one Arogya
Raksha Certificate in any one year. She/he gets free treatment from the hospital, which in turn
claims the charges from the New India Insurance Company. In case of death due to any accident,
the maximum benefit payable under one certificate is Rs. 10,000.

B. Partnership between the Government and the non-profit sector

1. Involvement of NGOs in the Family Welfare Programme

• The MNGO (Mother NGO) and SNGO (Service NGO) Schemes are being implemented
by NGOs for population stabilization and RCH. 102 MNGOs in 439 districts, 800 FNGOs,
4 regional Resource Centers (RRC) and 1 Apex Resource Cell (ARC) are already in
place. The MNGOs involve smaller NGOs called FNGOs (Field NGOs) in the allocated
districts.

The functions of the MNGO include identification and selection of FNGOs; their capacity
building; development of baseline data for CAN; provision of technical support; liaison,
networking and coordination with State and District health services, PRIs and other
NGOs; monitoring the performance and progress of FNGOs and documentation of best
practices. The FNGOs are involved in conducting Community Needs Assessment; RCH
service delivery and orientation of RCH to PRI members; advocacy and awareness
generation.

The SNGOs provide an integrated package of clinical and non-clinical services directly to
the community

• The Govt. of Gujarat has provided grants to SEWA-Rural in Gujarat for managing one
PHC and three CHCs. The NGO provides rural health, medical services and manages
the public health institutions in the same pattern as the Government. SEWA can accept
employees from the District Panchayat on deputation. It can also employ its own
personnel by following the recruitment resolution of either the Government or the District
Panchayat. However, the District Health Officer or the District Development Officer is a
member of the selection committee and the appointment is given in her/his presence. In
case SEWA does not wish to continue its services, the District Panchayat, Bharuch would
take over the management of the same.

2. The Municipal Corporation of Delhi and the Arpana Trust (a charitable organization registered
in India and in the United Kingdom have developed a partnership to provide comprehensive
health services to the urban poor in Delhi’s Molarbund resettlement colony. Arpana Trust runs a
health center primarily for women and children, in Molarbund through its health center ‘Arpana
Swasthya Kendra’. As contractual partners, Arpana Trust and MCD each has fixed
responsibilities and provides a share of resources as agreed in the partnership contract. The
Arpana Trust is responsible for organizing and implementing services in the project area, while
the MCD is responsible for monitoring the project. The MCD provides building, furniture,
medicines and equipment, while the Arpana Trust provides maintenance of the building, water
and electricity charges, management of staff and medicine.

7
3. Management of Primary Health Centers in Gumballi and Sugganahalli was contracted out by
the Government of Karnataka to Karuna Trust in 1996 to serve the tribal community in the hill y
areas. 90% of the cost is borne by the Govt. and 10% by the trust. Karuna Trust has full
responsibility for providing all personnel at the PHC and the Health Sub-centers within its
jurisdiction; maintenance of all the assets at the PHC and addition of any assets if required at the
PHC. There has been redeployment of the Govt. staff in the PHCs, however some do remain in
deputation on mutual consent. The agency ensures adequate stocks of essential drugs at all
times and supplies them free of cost to the patients. No patient is charged for diagnosis, drugs,
treatment or anything else except in accordance with the Government policy. The staff salaries
are shared between the Govt. and the Trust.

Gumballi district is considered a model PHC covering the entire gamut of primary health care –
preventive, promotive, curative and rehabilitative

Similarly in Orissa, PPPs are being implemented for safe abortion services and social marketing
of disposable delivery kits. Parivar Sewa Sanstha and Population Services International are
implementing the Sector Investment Plan in the state.

4. The Government of Tamil Nadu has initiated an Emergency Ambulance Services scheme in
Theni district of Tamil Nadu in order to reduce the maternal mortality rate in its rural area. The
major cause for the high MMR is anon-medical cause - the lack of adequate transport facilities to
carry pregnant women to health institutions for childbirth, especially in the tribal areas. This
scheme is part of the World Bank aided health system development project in Tamil Nadu. Seva
Nilayam has been selected as the potential non-governmental partner in the scheme. This
scheme is self-supporting through the collection of user charges. The Government supports the
scheme only by supplying the vehicles. Seva Nilayam recruits the drivers, train the staff, maintain
the vehicles, operate the program and report to the government. It bears the entire operating cost
of the project including communications, equipment and medicine, and publicizing the service in
the villages, particularly the telephone number of the ambulance service. However, the project is
not self-sustaining as the revenue collection is lesser than anticipated.

Seva Nilayam also operates another program in the Theni district called the Emergency Accident
Relief Center for which the government has also provided a vehicle.

5. The Urban Slum Health Care Project the Andhra Pradesh Ministry of Health and Family
Welfare contracts NGOs to manage health centers in the slums of Adilabad. The basic objectives
of the project are to increase the availability and utilization of health and family welfare services,
to build an effective referral system, to implement national health programs, and to increase
health awareness and better health-seeking behaviour among slum dwellers, thus reducing
morbidity and mortality among women and children. To serve 3 million people, the project has
established 192 Urban Health Centers. Five ‘Mahila Aarogya Sanghams’ (Women’s Wee-Being
Associations) were formed under each UHC, and along with the self-help groups and ICDS
workers mobilize the community and adopt Behaviour Change Communication strategies.
The NGOs are contracted to manage and maintain the UHCs, and based on their performance,
they are awarded with a UHC, or eliminated from the program. Additional District Magistrates and
Health Officers supervise the UHCs at district level and the Medical Officer is the nodal officer at
the municipality level. The District Committee approves all appointments made by the NGOs for
the UHC staff. The Govt. of Andhra Pradesh constructs buildings for the UHCs; provide honoraria
to the Project Coordinators of the UHCs, medical officers and other staff; train staff members; and
supply drugs, equipment and medical registers.
6. In recent examples, collaboration that has developed between Government of Arunachal
Pradesh, VHAI and Karuna Trust in managing significant number of PHCs may be seen at
Annexure IV.

8
C. Partnership between the Government and a private service provider

Several examples for the above partnership could be quoted from the Indian experience:

1. Partnership between the Department of Family Welfare and Private Service Providers:

• The DoFW has appointed one additional ANM on contractual basis in the remote sub-
centers (which constitute 30% of all sub centers in C category districts in 8 states) to
ensure better emergency obstetric care under the RCH programme. Similarly 140 ANMs
could be appointed in Delhi for extending their services in the slum areas. The scheme
has been extended to the North Eastern states with effect from 1999-2000
• Public Health/Staff nurses have been appointed on a contractual basis at PHCs/ CHCs
having adequate infrastructure for conducting deliveries.
• In order to plug deficiencies in providing emergency obstetric care at FRU due to non-
availability of anesthetist for surgical interventions, states have been permitted to engage
the anesthetist from the private sector on a payment of Rs.1000 per case at the sub-
district and CHC level.
• With a view to supplement the regular arrangement, provision has been made for
engaging doctors trained in MTP as Safe Motherhood Consultant who will visit the PHC
(including CHCs in NE states) once a week or at least once in a fortnight on a fixed day
for performing MTP and other Maternal Health care services. These doctors will be paid
@Rs.500 per day visit.
• A scheme for reservation of sterilization beds in hospitals run by government, local
bodies and voluntary organizations was introduced in 1964 with view to provide
immediate facilities for tubectomy operations in hospitals. At present too, beds are
sanctioned to hospitals run by local bodies and voluntary organizations and grant-in-aid is
provided as per approved pattern of assistance.
• The Haryana Urban RCH Model is being implemented in 19 urban slums and benefits 15
lakh beneficiaries. In this model, a private health practitioner (PHP) has been identified to
provide comprehensive primary health care service to a group of 1000-1500 targeted
beneficiaries. S/he provides services related to National Disease Control Programme,
contraception, immunization, ambulatory care. The PHP gets an incentive of Rs. 100 p.a.
per beneficiary by the Government. The model is envisioned to be self-sustaining by the
5th year.
• A proposal has been submitted by PSS, Rajasthan to the GOI for establishing a
comprehensive RCH clinic in 3 districts, wherein PSS would provide services like
sterilization, MTP, spacing, ante/post natal care, immunization, RTI/STI. The cost to be
borne by the Govt. is Rs. 18 to 20 lakhs p.a. per clinic. With a view to ensure project
sustainability, the user fees is sought to be deposited in a bank account.
• The Samaydan Scheme in Gujarat aims to ease the problem of vacancies of specialists
in health and medical services. About 125 honorary and part-time specialists have been
appointed in rural hospitals under the scheme and the removal of age-eligibility criteria for
appointment of doctors in government services is also being considered.
• Under the Urban Health Care Project, the community base health volunteers in the urban
areas would roped in to provide primary health care in the urban slums of Gujarat. Their
activities would be monitored by CHC/PHC/PPU/Urban Family Welfare Center/Trust
Hospital and they would be paid a fixed monthly honorarium.

2. The Department of AYUSH envisages accreditation of organizations with the MoHFW for
research and development in order to be eligible for financial assistance under the
scheme of Extra Mural Research on ISM&H. The eligible organizations include R&D
organizations recognized by the Ministry of Science and Technology, Govt. of India; one
Government or semi-Government or autonomous R & D Institution under the GoI/State
Government/Union Territory; and one private R&D institutions registered under any
State/Central Act as Research Organization.

9
D. Partnership between the Government and a private sector and/or the non-profit sector
and/or a private service provider and/or multilateral agencies

1. The National Malaria Control Programme has involved the NGOs and private practitioners at
the district level for the distribution of medicated mosquito nets. (LOGISTICS)

2. Under the National Blindness Control Programme, District Blindness Control Societies have
been formulated, which are represented by the Government, non-government and private
sectors. The NGOs have been involved for providing a package of services

3. The National AIDS Control Programme has involved both the voluntary and private sector for
outreaching the target population through Targeted Interventions (WIDER COVERAGE)

4. The Revised National Tuberculosis Control Programme has involved the private practitioners
and the NGOs for the rapid expansion of the DOTS strategy. The non-inclusion of the private
providers had been one of the main reasons for the failure of the earlier programme. The private
medical practitioners serve as the first point of contact for more than two-thirds of TB
symptomatics.

The GOI has initiated a Public Private Mix (PPM) pilot project with technical assistance from
WHO in 14 sites across the country viz. Ahmedabad, Bangalore, Bhopal, Chandigarh, Chennai,
Delhi, Jaipur, Kolkata, Lucknow, Patna, Pune, Bhubaneshwar, Ranchi and Thiruvananthapuram.
The areas of collaboration with the NGOs include: community outreach; health education and
promotion; provision of DOTS and in-hospital care for TB disease; TB Unit Model; programme
planning, implementation, training and evaluation.

Presently, there are 550 NGOs and 200 Private Practitioners involved in RNTCP. Attempts are
also underway to involve the medical colleges in the programme.

5. The Rajiv Gandhi Super-specialty Hospital in Raichur Karnataka is a joint venture of the
Government of Karnataka and the Apollo hospitals Group, with financial support from OPEC
(Organization of Petroleum Exporting Countries). The basic reason for establishing the
partnership was to give super-specialty health care at low cost to the people Below Poverty Line.
The Govt. of Karnataka has provided the land, hospital building and staff quarters as well as
roads, power, water and infrastructure. Apollo provided fully qualified, experienced and
competent medical facilities for operating the hospital. The losses anticipated during the first three
years of operation were reimbursed by the Govt. to the Apollo hospital. From the fourth year, the
hospital could get a 30% of the net profit generated. When no net profit occurred, the Govt paid a
service charge (of no more than 3% of gross billing) to the Apollo Hospital.

Apollo is responsible for all medical, legal and statutory requirements. It pays all charges (water,
telephone, electricity, power, sewage, sanitation) to the concerned authorities and is liable for
penal recovery charges in case of default in payment within the prescribed periods. Apollo is also
responsible for maintenance of the hospital premises and buildings, and maintains a separate
account for funds generated by the hospital from fees for registration, tests and medical charges.
This account is audited by a Chartered Accountant engaged by Apollo with approval of the
Governing Council. Likewise, Apollo maintains separate monthly accounts for all materials used
by patients below the poverty line (including diagnostic services), which are submitted to the
Deputy Commissioner of Raichur for reimbursement. Accountability and responsibility for
outsourcing the support services remain with the Apollo.

The controlling authority of the Govt. of Karnataka is vested in its District Commissioner. A
Governing Council is established to review the performance of the hospital periodically (twice a
year), make recommendations to improve the administration and management and also resolve
any disputes that might arise. The ten-member council is chaired by the Karnataka Health

10
Minister and includes the Raichur District Collector, the Apollo CEO, the Principal Secretary, the
Health Secretary, the Finance Manager, the Hospital Operations Manager, Medical Directors and
local Members of the Legislative Assembly (as special invitees).

6. The Karuna Trust in collaboration with the National Health Insurance Company and the
Government of Karnataka has launched a community health insurance scheme in 2001. It covers
the Yelundur and Narasipuram Taluks. Underwritten by the UNDP, the Karuna Trust undertook
the project to improve access to and utilization of health services, to prevent impoverishment of
the rural poor due to hospitalization and health related issues, and to establish insurance
coverage for out-patient care by the people themselves. The scheme is fully subsidized for
Scheduled Castes and Scheduled Tribes who are below the poverty line and partially subsidized
for non-SC/ST BPL. Poor patients are identified by field workers and health workers who visit
door-to-door to make people aware of the scheme. ANMs and health workers visiting a village
collect its insurance premiums and deposit them in the bank.

The annual premium is Rs. 22, less than Rs.2 a month. If admitted to any government hospital for
treatment, an insured member gets Rs. 100 per day during hospitalization – Rs. 50 for bed-
charges and medicine and Rs. 50 as compensation for loss of wages – up to a maximum of
Rs.2500 within a 25-day limit. Extra payment is possible for surgery. The insurance is valid for
one year. If members want to continue the coverage, they must renew their membership and pay
the full premium.

7. The Government of Karnataka, the Narayana Hrudalaya hospital in Bangalore and the Indian
Space Research Organization initiated an experimental tele-medicine project called ‘Karnataka
Integrated Tele-medicine and Tele-health Project’ (KITTH), which is an on-line health-care
initiatives in Karnataka. With connections by satellite, this project functions in the Coronary Care
Units of selected district hospitals that are linked with Narayana Hrudalaya hospital. Each CCU is
connected to the main hospital to facilitate investigation by specialists after ordinary doctors have
examined patients. If a patient requires an operation, s/he is referred to the main hospital in
Bangalore; otherwise s/e is admitted to a CCU for consultation and treatment.

Tele-medicine provides access to areas that are underserved or un-served. It improves access to
specialty care and reduces both time and cost for rural and semi-urban patients. Tele-medicine
improves the quality of health care through timely diagnosis and treatment of patients. The most
important aspect of tele-medicine is the digital convergence of medical records, charts, x-rays,
histopathology slides and medical procedures (including laboratory tests) conducted on patients.

8. The Yeshasvini Co-operative Farmer’s Healthcare Scheme is a health insurance scheme

targeted to benefit the poor. It was initiated by Narayana Hrudayalaya, super-specialty heart
hospital in Bangalore, and by the Department of Co-operatives of the Government of Karnataka.
The Government provides a quarter (Rs. 2.50) of the monthly premium paid by the members of
the Cooperative Societies, which is Rs.10 per month. The incentive of getting treatment in a
private hospital with the Government paying half of the premium attracts more members to the
scheme. The cardholders could access free treatment in 160 hospitals located in all districts of
the state for any medical procedure costing upto Rs. 2 lakhs.

The premium is deposited in the account of a charitable trust, the regulatory body for
implementing the scheme. A Third Party Administrator – Family Health Plan Limited that is
licensed by Karnataka’s Insurance Regulatory and Development Authority. The FHPL has the
responsibility for administering and managing the scheme on a day-to-day basis. Recognized
hospitals have been admitted to the network throughout Karnataka, which are called as network
hospitals (NWH). These hospitals offer comprehensive packages for operations that are paid by
Yeshasvini. A Yeshasvini Farmers Health Care Trust is formed to ensure sustainability to the
scheme, which comprises of members of the State Government and the network hospitals. The
Trust monitors and controls the whole scheme, formulates policies, appointed the TPA and
addresses the grievances of the insured members or doctors.

11
Only the members of an agricultural cooperative society could join this scheme, and also all
members of a given cooperative society must become members of Yeashsvini. This ensures
increase in the enrollment rates. The Government, apart from the premium subsidy has provided
key access to the cooperatives. The Department of Cooperatives has provided an administrative
vehicle to popularize the scheme.

The major drawback of this scheme is that the poor farmers are not covered for all health related
issues but only for out-patient care and all expenses connected with surgery.

9. A Rogi Kalyan Samiti (RKS) was formed in Bhopal’s Jai Prakash Governement Hospital to
manage and maintain it with public cooperation. The RKS or Patient Welfare Committee or
Hospital Management Society is a registered society and the committee acts as trustees for the
hospitals responsible for proper functioning and management of the hospital. Its members are
from local PRIs, NGOs, local elected representatives and government officials. Participation of
the local staff with representatives of the locl population has been made essential to ensure
accountability. It functions as an NGO and not a government agency. It may utilize all government
assets and services to impose user charges. It may also raise funds additionally through
donations, loans from financial institutions, grants from government as well as other donor
agencies. The funds received are not deposited in the State exchequer, but are available to be
spent by the Executive Committee constituted by the RKS/HMS. Private organizations could be
contracted out for provision of the super specialty care at a rate fixed by the RKS/HMS.

At JP Hospital, RKS was formed due to lack of resources and other functional problems, which
acted as an impediment to timely, and quality health service delivery. Due to delay or no
disbursement of funds, creation of a hospital management society capable of generating
revenues became imperative. After the formation of RKS, the quality of services increased in
terms of 24-hour availability of doctors and medicine, diagnostic facilities, better infrastructure,
cleanliness, maintenance and timeliness of services. Through RKS, the hospital has also been
able to provide free services to patients below the poverty line.

10. A public/private DOTS model was established on a pilot basis in Hyderabad at Mahavir Trust
Hospital, which is a private non-profit hospital. This partnership also involves private service
providers like doctors and nursing homes. This new approach is known as PPM DOTS (Public
Private Mix DOTS). As there are virtually no government services in the area, the private sector is
a full substitute for the public sector. Individual private practitioners were involved in the DOTS
programme as they form the first point of contact for most of the TB patients both for quality
health care as well as convenience to refer to the private practitioners rather than the hospitals at
frequent intervals.

The Mahavir Trust Hospital acts as a coordinator and intermediary between the government and
private medical practitioners (PMPs). It also acts as a supervisor. The PMPs refer patients
suspected of having TB to the hospital or to any of the 30 specified neighborhood DOTS centers
operated by PMPs. The patients pay the fees to the PMPs. In addition to providing a referral
center for an hour every morning at their own expense, the doctor gains professional and
commercial benefits to their practice that far outweigh the loss of several patients who could
never afford proper treatment in any case. In turn the Mahavir TB clinic informs the private
practitioners about the progress of their patients throughout their treatment. The Mahavir Hospital
and the PMPs keep the records for the government. The government provides TB control policy,
training, drugs and laboratory supplies. Five outreach workers trace late or delinquent patients
and provide community mobilization.

All stakeholders gain an advantage through this partnership. The Mahavir Trust Hospital benefits
because the money spent on the DOTS service cures patients. The government benefits because
the DOTS medicine are properly used instead of being wasted or even contributing to the
development of drug resistant TB. The medicines are curing the patients and the spread of the

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