With over 12,760 hospitals and over 24,000 primary health care centers, public health care forms the backbone of India’s health care services. However, many studies on utilization of health care facilities indicate that citizens prefer private health care over state run public hospitals for the cost and quality of services provided. Research studies indicate that over 80% of citizens prefer to use private sector facilities for minor ailments, even when higher quality doctors are available at public hospitals. Studies also highlight 78% of household prefers to go to private sector to private sector for their cleanliness and professional handling of patients. Several studies indicate while many state run hospitals are staffed with better quality and more experienced doctors, it is the infrastructure and service issues that turn many patients away. Dismal sanitary conditions, long waiting times, lack of basic HMIS, high infection rates, and substantial clinical care are some key issues that force the public health care facilities out of choice set. The other significant factor is rude behavior of staff and functioning of the hospitals. While cost of treatment in government hospitals may be free, bribery, insensitive behavior, limited working hours dissuade the use of public health care systems. CAG audit reports also point out to inefficient use of public funds. Many hospitals had Digital X-Ray, Pet scan machines lying for years in open and rusted, as they could not hire competent staff to man the job. One eminent government administrator mulled about 40% of funds go unutilized and about 30% of the instruments including OT end up as scrap as preventive maintenance is given a go by. Political interventions, inbreeding and bureaucracy precipitate inefficiency and apathy.
Several state governments in India have recognized the need to bring in efficiency, affordability and higher reach of state health care system. States of Karnataka, Gujarat, Kerala have introduced novel PPP mechanisms, including insurance schemes to cover the economically weaker sections. While exceptions like Jayadeva Hospital, Bangalore and Rajiv Gandhi Cancer Research Institute, New Delhi may exist, many suffer from poor infrastructure, lack of motivated staff, poor sanitation and hygiene issues. State governments have brought in concrete steps to address service quality and implement continuous quality improvements. While insurance and other related PPP interventions have certainly improved the access to better quality health care to underprivileged population. However, the fundamental issue with improving the hygiene and service quality of government run hospitals has not been addressed. Governance, management of efficiency and effective utilization of resources has been given a go by.
Should state governments adopt a proven PPP approach used in military complexes to efficiently run the hospitals. Government Owned Contractor Operated (GOCO) model is a proven model where industrial, academic and non-profit organizations manage government national labs. A GOCO model enables each partner to perform relevant duties. The government subsidizes the healthcare mission, increases reach and use of affordable healthcare, while private sector implements the mission and manages using best business practices. Several state governments, Karnataka, TN, J&K, Maharashtra have tried limited GOCO approach by letting 3rd party private players run and manage the diagnostic facilities. Private firms (install) or manage the machinery, maintain and offer the services at prescribed government rates to reach out across various segments. Below poverty line (BPL) families benefit from affordable diagnostic services and public funds are effectively used to primarily serve the healthcare mission and generate revenues.
While this limited outsourcing has brought in technical efficiency in only one department, overall management and effectiveness need further exploration. State governments must explore complete GOCO approach to allow private partner to run the hospital efficiently. Many challenges like insufficient doctors, inability to attract specialists, lack of appropriate rewards and recognition systems to motivate employees, that currently affect state run hospitals to achieve greater heights can be rightly addressed by GOCO partner. The GOCO partner a trust or an academic institution or an industry partner can bring managerial efficiency and high quality delivery focus, while state governments can successfully pursue appropriate investment and high impact mission goals.
However, switching over to the GOCO model is not going to be easy. State governments need strong political will, transparent and efficient process to identify the right partners and importantly the right structure and process to manage the GOCO contract. Creation of an independent board under the chairmanship of district administration with members consisting of prominent citizens, elected representatives, members of Medical council, GOCO partner is a must. GOCO operations must also be aligned with the health mission using performance frameworks such as results based framework (RBM).