Part 2: Linkages for Scale-up: Harnessing the Public Sector in Pakistan

In this second of a three-part blog series on the IRD-CHMI Health Market Innovations Hub in Pakistan, we provide an overview of the key discussion points and lessons learnt around public sector linkages at the meeting of the Hub Working Group members. An overview of the IRD-CHMI Health Market Innovations Hub can be found here.


Private organizations providing health services to low-income populations often look towards government support as a means for ensuring sustainability and scale-up of services. Whilst governments can be an important source for leveraging resources, effective partnerships for scale can be difficult to achieve given varying organizational mandates, priorities and commitments for budgetary allocations. In Pakistan, there are limited examples of large-scale public sector linkages within the health market innovations space. Although several philanthropic organizations have been successful in developing partnerships with governments, healthcare delivery remains very fragmented and there is great need for harmonization.  Public sector linkages were one of the key thematic topics for the IRD-CHMI Hub Working Group meeting. The organizations present were active in a broad spectrum of public health disease areas allowing for the discussion of several public sector engagement models. The session was facilitated by Athar Osama, founder of the Pakistan Innovation Fund and a World Economic Forum Young Global Leader.

Environments that facilitate development of public-sector linkages

Participants stressed that lobbying for health was more broadly needed within the government for a better enabled public-private partnerships environment; the current political priorities are focused around terrorism, the energy crisis and foreign relations. In order to support advocacy for public health issues that lack sufficient attention, the need for harnessing the rapid growth of the electronic media in the country was discussed.  Two of the media’s current healthcare hot-topics have been limited to diseases such as dengue, a disease that has affected the affluent, and polio eradication given the intense international spotlight on the country.  Diseases such as tuberculosis or hepatitis that have greater health burdens struggle to receive similar kinds of coverage and subsequently do not take shape as part of a political agenda. The context for public-sector linkages is therefore tied to the type of public health issue in question. Public sector linkages may be easier to develop for the MDGs, where there is international focus or where government programs, tackling these issues, are already in existence. Lobbying for diseases that have not made media headlines may be more challenging than other disease areas.

Target niche areas

Public sector support may emerge where programs have technical expertise in niche areas such as TB or vaccine delivery. This may be more practical in cases where vertical government programs are already in existence as it offers natural room for collaborative activities. If the technical work is being carried out with sufficient quality and at suitable scale, then the government will be able to take notice and cooperate. At the other end, certain domains such as emergency medical services in Sind province are provided almost entirely by the private sector. Governments may find few incentives to provide operational support in such instances due to lack of expertise; however, this may provide opportunities for government service contracting.

Participants discussed ensuring sustainability within programs as an effective way of gaining government trust. Often governments run into private sector programs delivering promising healthcare but ultimately creating a vacuum once funding has dried up. It was stressed that longer-term commitment needs to be shown in order to sustain innovation (read more about sustainability designs here.) Programs seeking public-sector support should prepare for longer-term investments and demonstrate flexibility and patience with the government’s bureaucratic processes.

Using donors to leverage governments

Disparities may arise in instances where programs have received large funding through international donor mechanisms and programs struggle to utilize these funds for gaining influence within governments in ways that are beneficial to both stakeholders. In niche areas, governments are reliant on competent private sector organizations to provide technical input in grant development; this should be used to open the door for further linkages. Additionally, involving the public sector allows organizations to apply for larger programmatic grants.  Distribution of these grants should be carried out across government departments thus supporting linkage development.

Building public-sector networks

Relationship building within governments is often time-consuming and rapid turnover rates of staff, in certain provinces, can be a particular challenge. In provinces with less centralized governments, understanding the local contexts, identifying local champions as well as elders, and tribal leaders to support initiatives can be of great benefit. Alternatively, it was suggested that involving former public sector employees within programs can improve credibility and build networks with the public sector.  The presence of multiple stakeholders within the government and delegation of authority at various levels both horizontally and vertically, was cited as a challenge. Programs often require approvals from various levels and need to comprehend that this will be a protracted process. Involving individuals that are well aware of these multiple hierarchies and the intricacies of government bureaucracies can be of great value.

Recommendations for the government

The Hub members were of the opinion that the creation of a neutral body ,within the government, that can be approached for lobbying on the behalf of private sector groups can support the development of health market innovations in Pakistan. The function of this group would range from developing guidelines and procedures for private sector programs, to identifying and carrying out negotiations on their behalf. The composition should include individuals that have relevant experience and networks within the government but also one that can make impartial decisions when supporting organizations. Governments should also be encouraged to contract out healthcare services in certain areas through competitive and transparent processes to improve programmatic efficiencies.

Photo by Vicki Francis of a female doctor running a DFID-funded mobile clinic, used courtesy of the Department of International Development.