Globally, governments are being urged to come up with strategies to expand affordable and quality healthcare to their populations under the United Nations’ Sustainable Development Goals (SDG) for health. As a signatory to the UN 2030 Agenda, Pakistan has committed to moving towards Universal Health Coverage (UHC), the upfront global target for all countries under the UN, which includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation and palliative care across the life course.
Pakistan has a large private health sector which is very much entrenched in the DNA of the country’s health system. Overstretched government delivery systems, because of increasing population and inadequately staffed and stocked government facilities, have led to private providers filling the service gaps for the affluent, the poor and the struggling middle class alike.
But can private-sector engagement deliver effective results? And how best can the private sector be engaged for affordable, quality healthcare? This needs to be unravelled before blindly embracing public-private partnerships.
National surveys show that more than 70 percent of health consultations take place in the private sector, and more than 90 percent of total clinics/ first-level care facilities are in the private sector, as per official mapping studies.
Another area where private health providers have made deep inroads is laboratories and diagnostic imaging (X-Ray, ultrasound, MRI, CT-Scan). More than 60 percent of registered laboratories are managed by the private sector. Hospital services are still largely catered by the public sector, particularly for the underprivileged: only one-fifth of the country’s hospital beds are in the private sector, while the rest are catered by the public sector’s teaching hospitals, civil / district hospitals, parastatal hospitals and military-run hospitals.
What lessons can be learnt from existing public-private partnerships for primary healthcare provision?
A reasonable starting point, then, for engaging private providers is primary health care — engaging clinics and diagnostic facilities to expand accessible, affordable care. This is where Pakistan’s government infrastructure is thin, and private providers are the main recourse for much of the population.
The problem is highly acute in Pakistan’s expanding cities and town centres in the rural districts, which bear the onslaught of population growth, but the government’s pre-colonial health infrastructure comprises hospitals that have an almost non-existent network of primary health centres.
But how have we dealt with this? Successive policymakers have emphasised investment in hospitals — hospitals are big, visible and win votes. Government budgets continue to tilt towards hospital spending and successive health insurance initiatives over the last decade have focused exclusively on in-patient hospital care.
The problem is that, unless affordable primary health care with diagnostic services is made accessible to the poor and less affluent groups, basic health issues will continue to complicate and land the population into hospitals — for example, simple hypertension, left unmanaged at the primary-care level, leads to kidney failure, undetected diabetes leads to stroke, hepatitis-C unscreened at the primary care level leads to liver failure.
A sparse network of affordable primary care outlets leads to a bucket of problems — unnecessary overcrowding of hospitals, strained government resources for free hospital care and a burden on the pockets of those paying for care. In short, a leaky bucket of public expenditure and arguably little health gains as many health issues could have been avoided.
This brings us to the next question: Can state funding of private providers deliver effective results for primary health services to the poor?
ASSESSING EXISTING INITIATIVES
Pakistan does have some examples to provide initial lessons.
One noticeable example is Sindh’s public-private initiative for primary healthcare, whereby private providers have been brought in to manage several government-run primary care health facilities, to improve delivery of services.
The services are provided free of cost and are guided by the Sindh government’s Essential Health Services Package, which was developed during the early days of devolution under the 18th Amendment. Since the primary health facilities are based in rural areas, it can arguably be seen to benefit the disadvantaged and the poor.
National surveys show that more than 70 percent of health consultations take place in the private sector, and more than 90 percent of total clinics/ first-level care facilities are in the private sector
Our recent performance assessment shows promising results and identifies opportunities for maximising health gains. Visible improvements over government-managed facilities are cleanliness, clinical waste disposal, electricity back-up, fewer stock-outs of medicines, availability of essential equipment and health guidelines for patient care. This has resulted in high volumes of outpatient consultations, pregnancy care visits and maternal deliveries, verified by independent assessors.
There is still room for improvement in other areas. For example, family planning provision for maternity clients, or disease screening of adults turning up in OPDs for hypertension, diabetes, hepatitis, etc., by providing disease control targets and building up government capacity for monitoring.
There have also been challenges in delivery. One challenge is ensuring staffing, as staff on government payroll does not always comply to serve in rural areas, with private providers hiring contractual staff to cover staff shortfalls. Another area is to meet the demand of the rising patient volumes with the available health facility resources — a common challenge seen when responding to the unmet needs of the poor.
An earlier countrywide initiative, the President’s Primary Healthcare Initiative, grew from an innovative pilot in district Lodhran, Punjab, funded by a private provider to manage government-run Basic Health Units from 2008-2012. This, too, revealed promising results: well maintained and better equipped facilities with higher outpatient and maternity volumes, although less impact on immunisation and family planning services was recorded.
Going back a little further in the era of district devolution, there were also small-scale instances of district governments funding medical charities. A prominent example is from Battagram in Khyber Pakhtunkhwa, where a number of public-sector health facilities debilitated by the 2005 earthquake were contracted to a non-governmental organisation (NGO) with reportedly positive results in medicine, supplies, staffing and patient numbers.
In Sindh, the private-sector engagement initiative has more mature design features compared to the older initiatives in Pakistan, such as more formal contracts based on a defined Essential Health Services Package, at least some level of target-setting, competitive selection of private health providers rather than a selective single NGO of choice, and legal frameworks drawn from a larger public-private partnership initiative across sectors.
Many private providers are wary of entering monetary arrangements with the government, as commercial gains can be made without recourse to state funds
In all the instances cited above, whether originating from Khyber Pakhtunkhwa, Punjab or Sindh, the premise has been the same — pulling in private providers at government health facilities to ensure at minimum the availability of services and at best deliver higher quality services.
So where do we go from here?
Current and past initiatives provide encouraging proof that government funding to private providers for service delivery in poor and disadvantaged areas can work in Pakistan. But to fulfil the UHC 2030 criteria, much more needs to be done and more strategically.
Government health facilities, even if running at 100 percent capacity through private provider arrangements, cannot be sufficient to meet the health service needs of our overpopulated country. Setting up more state-funded infrastructure is time-consuming, more costly and the effort can be duplicative, with both public and private providers competing for the same patients.
Government primary health outlets — dispensaries, basic health units, rural health centres — must be supplemented through the funding of existing private provider networks of clinics, polyclinics, laboratories and maternity homes, etc., for basic minimum services to the poor, at free or subsidised rates. These can serve as stand-alone primary health care initiatives to supplement the government’s own infrastructure, or they can be attached to existing hospital-focused insurance schemes.
In developing countries with an entrenched private health sector similar to Pakistan, for example Egypt and Iran, state-funded family practices have been set up with private clinics and NGOs to provide a basic package of curative care and disease prevention services in defined localities.
The family practices also act as gatekeepers for referrals to hospital insurance, reducing unnecessary and expensive hospital overuse. In India, maternity services have been expanded for the poor, with state funding, to private-sector maternity homes and clinics. A prominent example from a developed country setting is from the United Kingdom, where neighbourhood general practitioner clinics are contracted and funded as part of the National Health Services, and regulated for quality of care.
The penny needs to drop in Pakistan’s policy corridors that more funding commitment is required for affordable and accessible primary care services purchasing — inevitably but cautiously — from private health providers. Research from the Pakistan context also provides useful pointers to support a more strategic rollout of public-private partnerships.
STEP BY STEP
First, professionally licensed private provider clinics and laboratories are amply seen in urban centres and towns, which can serve as reasonable starting points rather than remote areas, where the so-called private sector comprises mostly unlicensed providers or quacks practising as doctors.
Second, private providers tend to overlook preventive care services, such as screening for basic diseases, nutrition counselling and family planning, unless they are given quality leadership.
Third, sustainable financing is critical, as private providers lose interest and exit public-private arrangements when there are cash flow problems and delayed financial releases. Typically, in Pakistan, contracts with private providers financed from recurrent budgets have flowed more smoothly than when financed from slow-moving development funds.
Fourth, the motivations of private providers to make public-private engagement work need to be understood for them to really work. Many private providers are wary of entering monetary arrangements with the government, as commercial gains can be made without recourse to state funds. While the Covid experience successfully brought in several highly professional private laboratories to report testing for the government, many private providers preferred to confine this to data-sharing arrangements and in-kind support for PCR kits.
Large private providers, when questioned, emphasise the importance of trust and goodwill within the government as the main factor for entering into partnership agreements for service provision. Public recognition also matters such as, for example, that gained from operating well-functioning paediatric emergencies within public-sector hospitals.
Smaller private providers report that the opportunity for training, accreditation and positive branding are the pull factors for potential partnership arrangements. This will enhance local standing and lead to self-development. Smaller private providers also prefer to partner under the umbrella of medical universities, medical charities and NGOs rather than directly with the state.
It is time to have a national strategy for moving towards primary health care under UHC; the hospital-centric focus is too limiting for health gains and too expensive to fulfil the unmet need for basic care. Sustainable funding, realistic service packages, defined pro-poor geographies, some extent of quality regulation by the government and creating communication platforms will be key ingredients.
The starting points and pathways for engaging private providers with state funds can differ across provinces, under common national goals. Above all, evolving experience from Pakistan and other countries shows that there is no perfect model of public-private arrangements, and that patience and persistence is required.
The writer is a professor of Health Policy and Systems at the Aga Khan University.
She has served as an expert to UN agencies and the World Bank on private sector engagement.
The views expressed are the author’s and not the institution’s
Published in Dawn, EOS, January 9th, 2022