Evaluating Public Private Partnerships

Given the increasing popularity of Public Private Partnerships (PPPs) in India, there is a need to evaluate the impact and effectiveness of existing PPPs in order to strengthen them and to better equip and inform future PPPs. In this context, ACCESS Health International has undertaken a comparative case study of mobile medical units (MMUs) in Bihar and Madhya Pradesh with the objective of understanding and analyzing the functioning of the program. The case focuses on the monitoring and evaluation mechanisms of the program, and provides recommendations to strengthen these mechanisms. The case was developed through interviews with public and private partners, field visits, and secondary research.

The National Rural Health Mission (NRHM) has identified mobile medical units as a strategy for improving access to healthcare in remote rural areas. The units would cater to primary health care needs. These units could either be operated by the state governments on their own or in partnership with private providers.

Adopting the Program

The state of Bihar adopted the MMU scheme under the name “Arogya Rath” in 2009 with three private providers. There are altogether 38 mobile medical units in the state, one for each district. The units provide primary health care services free of cost to people in underserved areas of the state. The private partners are responsible for providing infrastructure, manpower and services, and are given a target of serving at least 50 patients each day, operating for 26 days in a month.

The state of Madhya Pradesh had launched mobile medical units in the state as early as 1988-89 under a program called “Jeewan Jyoti Yojana” which was operated by the government itself. When the scheme was restructured according to NRHM guidelines and reintroduced in 2006 as “Deen Dayal Chalit Aspatal Yojana”, it was decided that private partners would be engaged to provide services, in order to address issues of managerial constraints and high costs. Currently, 92 mobile units are under operation in the state, with one unit for each tribal block.

Both states used a competitive bidding process with weightage given to technical and financial aspects. The bidding process in Bihar was centralized, with the State Health Society Bihar (SHSB) issuing a single invitation to bid for all the districts. The bidding process in Madhya Pradesh was decentralized, with each District Health Society issuing invitations to bid for the blocks within that particular district only.

The Units

The mobile units used in Bihar are air-conditioned and equipped with an operating table and accompanying accessories as well as an x-ray room and processing unit. Each unit is manned by a staff of eight. The mobile units in Madhya Pradesh, which do not provide for these facilities, are manned by a staff of four. One of the biggest challenges that the private providers face is the high rate of attrition, caused by the difficult working conditions, constant travel and long hours.

The services provided in the units in Bihar and Madhya Pradesh remain the same, but for a few exceptions which cater to localized needs. The monthly payment for a unit in Bihar was INR 468,000 (USD 9,360 USD) versus INR 175,000 (USD 3,500 USD) for a unit in Madhya Pradesh. The cost per patient for the private provider was also significantly higher in Bihar (USD 6.18) than in Madhya Pradesh (USD 1.66). The average number of patients seen by a unit per visit in Bihar averaged to 126, whereas in Madhya Pradesh the average was 92.

Monitoring and Evaluation

The monitoring and evaluation component was not found to be very robust in either of the states. There was no separate budgetary allocation for monitoring and evaluation mechanisms in the contracts. The performance parameters listed in the contracts are not clearly defined. Moreover, the monitoring reports used do not capture the data required to measure performance on these parameters. Verification of the data collected is a further challenge, with no fraud control mechanisms in place. Finally, the focus so far has been on quantitative data only, while measurement of service quality has largely been ignored.

While a large amount of data is being collected in both states as part of the reporting process, there is no analysis of this data. In Bihar, though the contract provided for an evaluation six months into the program launch, no such evaluation has been conducted. In Madhya Pradesh, there is no provision in the contract for beneficiary feedback or for independent evaluations.

Recommendations

An effective monitoring and evaluation mechanism is invaluable in identifying gaps and strengthening the program for better performance. It is recommended that the NRHM guidelines should provide guidance to the states on designing monitoring and evaluation mechanisms for the MMU program. The program must provide for a separate budgetary allocation for the monitoring and evaluation component to ensure that it does not get neglected.

The performance parameters need to be clearly defined in the contract, with provision for including service quality parameters. States must develop reporting and monitoring systems that capture appropriate data to measure performance against agreed upon parameters. Both public and private partners need to put in fraud control mechanisms in order to ensure the accuracy of the data. It is also recommended that the states make provision for regular third party evaluations to be conducted in order to assess the program performance.

Conclusion

Mobile medical units have reached out to hundreds of villages and millions of beneficiaries since the start of their operations. Yet there are many challenges to their effective functioning. Providers face many operational challenges on a daily basis – ensuring staff presence, ensuring adequate drug supply, dealing with contingencies, etc. For state governments, ensuring private provider performance through effective monitoring and evaluation is a major challenge.

The Government of India, through the NRHM, has a role to play in strengthening the program. However, it is the state governments that have to undertake a stewardship role – designing and developing the program, adapting it to meet local needs, monitoring private providers to ensure performance, evaluating the program at periodic intervals to make course corrections where necessary, and supporting local government authorities as well as the private partners in all ways possible to ensure the success of the program.

The comparative case study ‘Mobile Medical Units in Bihar and Madhya Pradesh’ has been authored by Annapurna Chavali, Ramya Kancharla and Prabal V Singh of ACCESS Health International and is available below.