The recent proclamation of the Punjab government to hand over management of all public health facilities in 10 districts to private parties to ‘improve’ service delivery has stirred a debate among the stakeholders -- whether the state is withdrawing from its responsibilities to provide basic facilities to its people.

The plan -- to be tentatively implemented by the end of this year aims at outsourcing to private organisations the management of public health facilities of 10 districts, including Bahawalnagar, Bhakkar, Chiniot, Hafizabad, Jhang, Khushab, Nankana Sahib, Narowal, Okara and Pakpattan. The government will continue to have an oversight role.

Punjab Minister for Finance Ayesha Ghous Pasha announced the plan on the floor of the assembly recently.

The Punjab government plans to eventually replicate this model in all 36 districts of the province.

There are 669 health facilities in 10 districts which include 11 district headquarter hospitals (DHQs), 25 tehsil headquarter hospitals (THQs), 67 rural health centres (RHCs) and 566 basic health units (BHUs).

The province has a total of 27 DHQs, 104 THQs, 300 RHCs and 2,500 BHUs. "The government has been in discussion with foreign consultants, including the World Bank and DFID for the past two years to make this plan possible," a senior official of Punjab Health Department tells TNS on condition of anonymity.

According to the plan, the day-to-day operations and management will be contracted out. The contractor will be responsible for the management of human resource; maintenance of infrastructure; maintenance of furniture and equipment; procurement and provision of medical and non-medical supplies and consumables; enforcement of clinical and hygiene protocols; training of staff; employees’ efficient practices that ensure patient satisfaction; hiring of staff against vacant posts; ensuring efficient referral system; and detailed and accurate maintenance of patient record.

The contract will be for three years and further extendable for two years, based on annual reviews and third party validation. Infrastructure and equipment will remain the property of the government.

A draft circulated among the stakeholders states that the Punjab Health Department, as part of the Chief Minister’s Health Reforms Roadmap, has identified significant gaps in service delivery at primary and secondary level healthcare facilities. Primary level facilities include BHUs and RHCs.

"Even when the facilities have basic necessities available, the quality of care provided to patients is not always of the highest standard thus resulting in low overall patient satisfaction. Evidence suggests that if implemented correctly, outsourcing the management of health facilities can help ensure delivery of consistent high-quality care to the population," the draft states.

Governments in some countries have implemented this strategy to improve specific aspects of healthcare delivery. In Pakistan, too, the governments of Punjab, Sindh, and the Khyber Pakhtunkhwa have, in a number of instances, contracted out the management of healthcare to non-government providers with varying results.

According to the draft, for Punjab in particular, the contracting out of BHUs in 14 districts to Punjab Rural Support Program (PRSP) has yielded some improvements. One of the key lessons from this experience has been to ensure that when contracting out, a detailed contract must be written between the parties, with close monitoring and follow up: the aim is to ensure an overall increase in the quality of healthcare delivery by guaranteeing that all the essential elements are available at the facilities, states the draft.

However, Dr Ashraf Nizami, central president of Pakistan Medical Association (PMA), outrightly rejects the plan, saying that the government, first, should loudly admit its failure to run public health facilities rather than making it ‘public-private partnership’. He says that previously, the experience of handing over BHUs to Punjab Rural Support Programme (PRSP) had also failed and audit reports clearly point that out. He says by transferring health facilities to private contractors, the government will be compromising on service delivery and covering the government’s negligence and mismanagement.

He warns that PMA will openly oppose this plan.

"The solution lies in making health facilities’ management more professional, independent and merit-based," says Dr Nizami. "Also there is a need to allocate at least 4-6 per cent of the budget for health which is currently even below one per cent. Provision of healthcare facilities is the responsibility of the state. The decision is reflects the failure of both the political government and the health managers."

He says that such private contractors were given charge of health facilities in Afghanistan and KP because they were conflict zones and the governments had lost its writ there.

Contracting out the management of primary and secondary healthcare has four main aims: ensuring availability of the basics required to run the facilities such as staff, medicines and supplies, better maintenance of infrastructure, better services and more equity.

A senior official in the Punjab Health Department says the public-private partnership in the healthcare will merely change the means of services. "The focus is on governance," says the official.  "There will be third party evaluation and a whole project monitoring unit. A team of consultants of DFID and others is working on it along with the Punjab government."

The KP government is running such a model successfully in five districts, including Batagram, Buner, Bannu, Kohistan and Karak. Similarly, the Sindh government is also likely to sign an agreement with an external party to outsource the basic health facilities in two districts of Thatta and Badin.

Dr Mansoor Hussain, a columnist for this newspaper and former professor at King Edward Medical University, doubts these plans of the government. "It is a fraud. The government will have to disclose the incentives for the contractor. Without incentive no party can enter this huge plan."

He says that such projects are viable only at a small local level. "Local governments have a big role in these plans. At the moment we clearly do not see it."

He raises many pertinent questions, such as who will be hiring the doctors, where will they come from when already there is a shortage of qualified doctors? He believes this is a plan to privatise health facilities, refusing poor people their right to healthcare and urges the authorities to improve the current system and run it in a professional way.

The online version of this article has been updated to attribute a paragraph to its original source.