Public-Private Partnership to Accelerate

Family Planning Uptake in Pakistan:

A Conceptual Framework

July 2019
The Population Council confronts critical health and development issues—from stopping
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ii
Table of Contents
Acknowledgements ............................................................................................................................... iv
Acronyms ................................................................................................................................................ v
Introduction ............................................................................................................................................ 1
Background ............................................................................................................................................ 2
Rationale for Public–Private Partnerships ............................................................................................. 5
Approach ................................................................................................................................................ 9
Findings from Existing Literature on PPP ............................................................................................ 10
Definitions – What is a Public-Private Partnership? ........................................................................... 10
Existing PPP Models in Pakistan .......................................................................................................... 12
Findings from Provincial Consultations ............................................................................................... 15
Conceptual Framework for PPPs for Family Planning ......................................................................... 18
Step 1: A SWOT Analysis – What the Public and Private Sectors Can Offer ..................................... 18
Step 2: Potential Areas for Developing PPPs for Family Planning ..................................................... 19
Step 3: Creating the Enabling Environment for PPP ........................................................................... 20
Proposed Public-Private Partnership Framework................................................................................ 20
Operationalizing the PPP Framework .................................................................................................. 24
Timelines for Implementation of the Framework ................................................................................ 24
PPP Framework Evaluation Model ....................................................................................................... 25
Conclusions ......................................................................................................................................... 26
Annexures............................................................................................................................................ 27
Annex - 1 Feedback from provincial consultative meetings for developing PPP framework ........... 27
Annex - 2 Global PPP Experiences ....................................................................................................... 30
Annex - 3 Glimpses from provincial consultative meetings for developing PPP framework ............ 32

iii
Acknowledgements
The development of this Conceptual Framework for Public–Private Partnership in Family Planning was
commissioned by the United Nations Population Fund (UNFPA) and carried out by the Population
Council, Islamabad. We would like to thank the Department for International Development, UK (DFID)
for generous financial support. We thank colleagues from UNFPA who guided us and participated
through this project, including Dr. Jameel Ahmed, Dr. Yilma Mfkamu, Dr. John Pile, Dr. Rashid Ahmed,
and Mr. Shoaib Ahmed Shahzad.
We appreciate in particular Mr. Abdul Ghaffar Khan, Director General, Population Program Wing,
Ministry of National Health Services, Regulations & Coordination for his keen interest and facilitation
and for appointing Mr. Nafees Ahmad as the focal person for this project.

Within the Population Council’s Islamabad office, we appreciate Ms. Samia Ali Shah, Project Director,
for her oversight and inputs and we also acknowledge Ms. Kiren Khan for her editorial support and
Mr. Ali Ammad for formatting and laying out this document.
We would also like to thank all the participants of the provincial and national roundtable meetings for
their insights and active participation in shaping this conceptual framework.
We offer our appreciation and gratitude to the officials of the Health and Population Welfare
departments of the Punjab, Balochistan and Khyber Pakhtunkhwa provinces, as well as the federal
government, for their full support and facilitation of the roundtable consultative meetings.

Authors

Rehana Ahmed
Ali Mohammad Mir
Iram Kamran
Rehan Niazi

iv
Acronyms
ADP Annual Development Program
BCC Behavior Change Communication
BHU Basic Health Unit
BMC BioMed Central
BMGF Bill and Melinda Gates Foundation
CCI Council of Common Interests
CIP Costed Implementation Plan
CPR Contraceptive Prevalence Rate
CMW Community Midwife
CSR Corporate Social Responsibility
DoH Department of Health
DKT Deutsche Kautschuk Tagung
ESSI Employees Social Security Institution
FP Family Planning
FBO Faith-based Organization
FWA Family Welfare Assistant
FWW Family Welfare Worker
GSM Greenstar Social Marketing
HANDS Health and Nutrition Development Society
HLFPPT Hindustan Latex Family Planning Promotion Trust
IHS Integrated Health Services
IUCD Intrauterine Contraceptive Device
LHV Lady Health Visitor
LHW Lady Health Worker
LMIC Low- and Middle-Income Countries
LAM Lactational Amenorrhea Method
MCH Mother and Child Health
MIS Management Information System
MSI Marie Stopes International
MSS Marie Stopes Society
MSU Mobile Service Unit
MoU Memorandum of Understanding
MVA Manual Vaccum Aspiration
mCPR Modern Contraceptive Prevalence Rate
MNCH Maternal Neonatal Child Health
MWRA Married Women of Reproductive Age
NGO Non-Governmental Organization

v
PPHI People Primary Health Initiative
PWD Population Welfare Department
PPIUCD Postpartum Intrauterine Contraceptive Device
PDHS Pakistan Demographic Health Survey
PPP Public–Private Partnership
PPM Public–Private Mix
PSI Population Services International
PSDP Public Sector Development Program
PRSP Punjab Rural Support Programme
PSS Parivar Seva Senstha
RHC Rural Health Center
RH Reproductive Health
SDG Sustainable Development Goal
SIFPSA State Innovations in Family Planning Services Project Agency
SHOPS Strengthening Health Outcomes through the Private Sector
SRH Sexual and Reproductive Health
SMO Social Marketing Organization
SWOT Strengths, Weaknesses, Opportunities and Threats
TFR Total Fertility Rate
TNVS Tanzania National Voucher scheme
UHC Universal Health Coverage
UNFPA United Nation Population Fund
USAID United States Agency for International Development
UPTS Uttar Pradesh Technical Support
VFM Value for Money
WHO World Health Organization

vi
Introduction
Pakistan’s alarming population growth rate, which was 2.4 percent between the 1998 and 2017
censuses, is now being recognized as a major impediment to the attainment of the country’s
development goals. The issue was highlighted in a Supreme Court Human Rights case in 2018,
bringing inadequate access to family planning (FP) to the forefront as a key development challenge. A
Supreme Court–appointed Task Force formulated eight key recommendations for addressing the
issue, and these were endorsed by the Council of Common Interests (CCI), which is headed by the
Prime Minister and comprises of all provincial Chief Ministers.
Among other important measures, the recommendations call for improving FP service delivery by
increasing collaboration between the private and public sectors and adopting innovative approaches.
One recommended approach is the fostering of partnerships between the public health sector and
civil society as well as the business community, as the government has limited resources for
achieving universal FP coverage (Recommendations 2.2 and 2.5). Joining forces with other
stakeholders will help in meeting Pakistan’s national and international commitments, including its
FP2020 goals as well as the Sustainable Development Goals (SDGs 3.1and 3.7).

To meet SDG Targets 3.1 and 3.7, countries must, by 2030, reduce the global maternal mortality
ratio to less than 70 per 100,000 live births and ensure universal access to sexual and
reproductive health care services, including family planning services, information and education,
and integration of reproductive health into national strategies and programmes. Moreover, SDG
Target 5.6, concerning women’s empowerment, calls for ensuring universal access to sexual and
reproductive health and reproductive rights as agreed in the Programme of Action of the
International Conference on Population and Development, the Beijing Platform for Action, and the
outcome documents of subsequent review conferences.

Private pharmacies, health service providers, and non-governmental organizations (NGOs) already play
an important role in FP service provision in Pakistan. With the demand for services unmet, there needs
to be a shift in how the public and private sectors respond jointly to achieve universal FP/reproductive
health (RH) coverage. Engaging the private sector for its expertise in supply chains, information
technology, data analytics, and client service will improve FP service provision more efficiently, with
greater impact, and on a more sustainable basis.
The objective of this analysis is to recommend a National/Provincial Conceptual Framework for Public-
Private Partnership for FP that can help provinces to weave such partnerships into their future plans,
including Annual Development Program (ADP) schemes, as well as applications for federal Public
Sector Development Program (PSDP) funding. Target audiences include both public and private sector
stakeholders, including policy makers, planners, program implementers, legislators, academics,
development partners, and civil society organizations.
The conceptual public–private partnership (PPP) framework and guidelines presented in this report
aim to provide a road map for creating the enabling environment needed to foster much-needed PPPs
for family planning in the country, with a clearer definition of public and private sector roles and
processes for legally binding partnerships.

1
Background
Pakistan’s family planning program was initiated in the early 1960s and has since been a part of
development planning. Yet, it has achieved only modest success as FP uptake trends show. By the
end of 2012, according to the Pakistan Demographic and Health Survey (PDHS) 2012-13,1
55.5 percent of all married women of reproductive age (MWRA) in the country wanted to either prevent
or delay their next childbirth by at least two years, but only 35.4 percent were using any method of
contraception. At the London FP Summit 2012, Pakistan committed to eliminate this gap by increasing
the contraceptive prevalence rate (CPR) in the country from 35.4 to 55 percent by 2020. The CPR goal
was later reset to 50 percent. After the 18th Constitutional Amendment and the resulting devolution
of powers, the provinces became responsible for setting their own goals and developing costed
implementation plans (CIPs) to achieve them.
Findings of the latest round of PDHS (2017-18)2 are disappointing and reflect the country’s poor
performance in the area of FP in the last five years, which is at odds with the significant improvement
achieved in maternal, neonatal, and child health (MNCH) indicators. The PDHS 2017-18 shows that
total demand for FP among MWRA has decreased by 4 percentage points from 55.5 in 2012-13 to
51.5 in 2017-18 (Figure 1).
Figure 1: Demand for family planning among MWRA from 1991 to 2018
100

80
54.5 55.5 51.5
60
39.4
40

20

0
PDHS 1991-92 PDHS 2006-07 PDHS 2012-13 PDHS 2017-18

Source: PDHS (all rounds)

Although unmet need for FP has decreased by 2.8 percentage points, from 20.1 in 2012-13 to 17.3
in 2017-18, this is not due to an increase in CPR but to a decrease in the demand for family planning,
as shown in Figure 2, which shows the proportions of MWRA who:
1) Either do not want to have more children or want to wait at least two years before their next
pregnancy (need for family planning),
2) Are currently using any method of contraception (met need), and
3) Are not using any method of contraception despite the need for family planning (unmet need).
The national CPR has decreased by 1.2 percentage points from 35.4 in 2012-13 to 34.2 in 2017-18.

1 National Institute of Population Studies (2013). Pakistan Demographic and Health Survey 2012-13. Islamabad.
Islamabad and Calverton, Maryland, USA: NIPS and ICF International.
2 National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2019. Pakistan Demographic and Health Survey 2017-
18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF.

2
Figure 2: Demand, met need, and unmet need for family planning in Pakistan among MWRA from 1991 to
2018

100

80
54.5 55.5 51.5
60
39.4 35.4
40 34.2
28 29.6
24.9
20.1 17.3
20 11.4

0
PDHS 1991-92 PDHS 2006-06 PDHS 2012-13 PDHS 2017-18

Need for family planning Met need Unmet need

Source: PDHS (all rounds)

Table 1 shows that the method mix has not changed, and the two most popular methods remain
female sterilization (8.8 percent) and condoms (9.2 percent). There is, however, a significant decrease
in the use of lactational amenorrhea method (LAM) from 1.5 percent in 2012-13 to 0.2 percent in
2017-18, and this is the main reason for the 1.1 percentage point decrease in CPR in 2017-18. An
encouraging finding of the survey is the emerging use of the newly introduced method of implants. Use
of all other methods is almost stagnant or shows only a nominal change between 2012 and 2018.
Table 1: Contraceptive prevalence rate and method mix in Pakistan, 1991-2018
Use of Contraception PDHS 1991-923 PDHS 2006-074 PDHS 2012-13 PDHS 2017-18
Any Modern method (mCPR) 10.7 21.7 26.1 25.0
Female sterilization 4.2 8.2 8.7 8.8
Condom 3.3 6.8 8.8 9.2
Pills 1.1 2.1 1.6 1.7
Injectables 0.9 2.3 2.8 2.5
IUD 1.2 2.3 2.3 2.1
Implant - - - 0.4
LAM - - 1.5 0.2
Other modern methods 0.0 0.0 0.4 0.1
Any traditional method 0.7 7.9 9.3 9.2
Withdrawal 0.5 4.1 8.5 8.1
Rhythm 0.2 3.6 0.7 1.0
Other tradition methods 0.0 0.2 0.1 0.1
Any method (CPR) 11.4 29.6 35.4 34.2
Source: PDHS (all rounds)

3
National Institute of Population Studies (NIPS) [Pakistan] and IRD/Macro International Inc. (1992). Pakistan Demographic
and Health Survey (PDHS) 1990-91. Columbia, Maryland: NIPS and IRD/Macro International Inc.
4 National Institute of Population Studies (NIPS) and Macro International Inc. (2008). Pakistan Demographic and Health
Survey 2006-07. Islamabad, Pakistan: National Institute of Population Studies and Macro International Inc.

3
Successive rounds of the PDHS also show a steady decline in fertility rates over time, from 5.4 births
per woman as reported in the 1990-91 PDHS to 3.6 births per woman in the 2017-18 PDHS—a drop
of about two births per woman in almost three decades (Figure 3). However, this decline in fertility
level has stalled in the last five years.

Figure 3: Trends in total fertility rate from 1991 to 2018

10

6 5.5
4.1 3.8 3.6
4

0
PDHS 1991-92 PDHS 2006-07 PDHS 2012-13 PDHS 2017-18

Source: PDHS (all rounds)

Figure 4: Sources of modern contraceptive
Among women’s reported sources of contraceptives in PDHS methods
2017-18, the public and private sectors have almost the same
share. However, private sector utilization goes up to 56 percent
if the proportion of ‘other sources,’ which include dais
13%
(traditional birth attendants) and hakims (practitioners of
alternative medicine), is included, since both are private
43%
providers (Figure 4).
44%
PDHS data indicates a decrease in mCPR from 26.1 in 2012-
13 to 25.0 in 2017-18. On the other hand, a comparison of the
contraceptive performance reports of the Pakistan Bureau of
Statistics for 2012-135 and 2016-176 indicates a significant Private medical sector Public sector

increase in the distribution of contraceptives by the public Other source

sector. One reason for this could be that the 2012-13 report Source: PDHS 2017-18
focused only on distribution by Population Welfare Department
(PWD) facilities and Lady Health Workers (LHWs) and did not include the contribution of Department
of Health (DoH) facilities, which are included in the 2017-18 report.
Meanwhile, the above-mentioned reports indicate that there has been no significant change in the
sale of contraceptives by the private sector (Table 2). But notwithstanding this stagnancy during the
last five years, the private sector is making a significant contribution to the promotion of contraceptive
use in Pakistan. It provides access to millions of MWRA by selling established brands of contraceptives
(condoms, pills, and injectables) at substantially subsidized prices through private service providers,
pharmaceutical outlets, and shops carrying fast-moving consumer goods. The Sathi and Touch brands

5
Pakistan Bureau of Statistics. 2014. Contraceptive Performance Report 2012-2013. Government of Pakistan, Statistics
Division, Pakistan Bureau of Statistics, Islamabad.
6
Pakistan Bureau of Statistics. 2019. Contraceptive Performance Report 2016-2017. Government of Pakistan, Statistics
Division, Pakistan Bureau of Statistics, Islamabad.

4
of condoms and Nova brand of pills marketed by Greenstar Social Marketing are the most popular
contraceptive products in the country (PDHS 2017-18). They are available for a nominal price at more
than 70,000 pharmaceutical and retail outlets across the country.
Table 2: Distribution of contraceptives to clients as reported by the public and private sectors, 2012 to 2017

Public sector Private sector

Family planning
commodities 2012-13 2016-17 Increase, % 2012-13 2016-17 Increase, %
Condoms (units) 73,742,775 160,319,484 117.40 114,708,689 113,690,918 -0.89
Pills (cycles) 3,366,476 15,353,073 356.06 3,206,626 1,065,019 -66.79
Injections (vials) 1,359,796 7,865,084 478.40 1,627,193 839,892 -48.38
IUDs (units) 777,663 946,524 21.71 642,801 754,820 17.43
Source: Pakistan Bureau of Statistics (PBS), Contraceptive Performance Reports for 2012–13 and 2016-2017

For private sector providers , family planning is a low-revenue service and therefore not a priority.
However, a Landscape study conducted by the Population Council in 2016 found that private providers
are interested in offering FP services, provided they receive refresher trainings to manage side effects
as well as a supply of contraceptive products.7

Rationale for Public–Private Partnerships

The global community acknowledges that the private sector is critical in the provision of FP as well as
other basic health care services in low– and middle–income countries (LMIC) and that the public
sector should leverage it for its capabilities as part of a total market approach. At the 63rd World Health
Assembly, it was resolved that it is incumbent to “strengthen the capacity of the governments to
constructively engage the private sector in providing essential health care.” This resolution
acknowledged that the private sector is a major source of health care in most countries and has been
effectively regulated and financed by governments in high-income countries, and that LMIC can
effectively engage and regulate this sector through formal PPPs to expand access to health care.
There is considerable scope for reducing the population growth rate through fast-track implementation
of PPPs for FP by all provinces. This potential arises, on the one hand, from the immense unmet need
for contraceptive services—17.3%, which translates into about six million potential users—and on the
other hand, from the large proportion of private sector providers who are not currently providing FP
services.
The public health sector does not currently have sufficient capacity to achieve universal coverage in
basic health care, which is a fundamental human right. A study to assess availability and motivation
of public sector providers found that public sector facilities are understaffed because vacant positions
are not being filled and staff motivation is low, negatively impacting quality of care.8 The public sector
budget is not increasing in real time and a large proportion of it is being consumed by non-development
expenditures, especially salary support. Developmental activities, including service expansion, are
therefore compromised. While PWD and the People’s Primary Healthcare Initiative (PPHI) are actively

7
Population Council. 2016. “Landscape Analysis of Family Planning in Pakistan.” Report and Brief. Population Council,
Islamabad.
8
Mir, Ali M., Gul Rashida, Saleem Shaikh, Neha Mankani, Anushe Hassan, and Maqsood Sadiq. 2013. "Assessing retention
and motivation of public health-care providers (particularly female providers) in rural Pakistan." Islamabad: Population
Council.

5
providing FP services, as are LHWs of the DoH, findings from a 2017 study show that the numerous
static facilities of DoH are not fully on board, with several opportunities for offering FP services being
missed.9

The private sector has the advantage of much larger numbers of service delivery points than the public
sector and is generally perceived to provide more client-centered care, but its services are less
affordable, especially for poorer segments of the population. Private practitioners in Pakistan are
engaged in managing a variety of health issues, providing both preventive and curative care, largely
due to relatively low capital requirements and high demand. This pattern involves them directly in core
“public health” activities such as treating patients with malaria, tuberculosis, and other communicable
diseases, as well as treating sick children and pregnant women. Despite widespread concern about
cost and clinical quality, patients often bypass public facilities to use private providers, frequently citing
reasons of convenience and responsiveness.
Unfortunately, many private health facilities do not offer FP services at present. A recent study found
only 41 percent of private providers in urban areas and 29 percent in rural areas were providing FP
services.10 Pharmacies were performing better, with 69 percent offering FP products in urban areas
and 53 percent in rural areas, but they were mostly selling condoms.
For optimizing the full potential of existing providers, there is a need for all sectors to play a role in
increasing demand for FP through provision of correct information, education and communication,
with the entire health sector leading in service provision. It is imperative for the government to initiate
tailored PPP schemes to achieve public health care goals utilizing the private sector, without deviating
from the general objective of fostering a publicly dispensed basic health system. Public-private
partnerships that capitalize upon the strengths of the two sectors and overcome their inherent
weaknesses can lead to accelerated uptake of FP services. A key challenge the private sector faces in
offering family planning as a stand-alone service is that it does not generate high enough revenue.
Therefore, PPPs should integrate FP in other revenue generating services such as maternal, child, and
primary health care.
By positioning family planning as a continuation of maternal and child health, and offering reasonable
monetary and non-monetary incentives, private providers—including doctors as well as mid-level
providers like Lady Health Visitors (LHVs) and community midwives (CMWs)—can be engaged in
delivery of family planning services all over the country. This will have several advantages. Firstly,
incentives from the public sector will make it sustainable for private providers to start providing FP
services or to increase the range of methods they offer. From the government’s perspective, the main
advantage will be a rapid increase in human resource availability and expanded outreach of FP
services. Secondly, private sector interest in FP service provision will also increase competition,
improving both efficiency and quality of care. This will improve client experiences of FP services and
could eventually reduce contraceptive discontinuation rates and also generate additional demand for
family planning through diffusion of information. Finally, PPP schemes will require the government to
collect more complete data about private health facilities, which will contribute to improving regulation
of the private sector, leading towards a more robust health system.

9
Rashida G., Kamran I., Khalil M., Khan M., Tasneem Z., Niazi R., Parveen T. 2017. “Increasing Access to Reproductive
Health Care through Improved Services Delivery.” Population Council, Islamabad.
10
Population Council. 2016. “Landscape Analysis of Family Planning in Pakistan.” Report and Brief. Population Council,
Islamabad.

6
Public-private partnerships can make the preventive and promotive aspects of health common goals
for private and public providers, with both sectors accountable for strengthening national policies and
programs, and the government leading in providing citizens their fundamental rights.

Tapping Existing Opportunities

The policy environment in Pakistan is already moving towards public-private partnerships in provision
of health services, including family planning. As mentioned earlier, taking cognizance of the alarming
population growth in Pakistan, the former Honorable Chief Justice of Pakistan took suo moto notice in
Human Rights case 17599 of 2018 and constituted a Task Force to formulate a mechanism to curb
population growth rate in the country. The Task Force’s recommendations11 and action plan specify
clear priorities, activities, roles and responsibilities, and timelines for actions. They were placed before
the Council of Common Interests and approved in principle on November 18, 2018. The
recommendations relevant to the private sector, along with corresponding activities in the action plan,
are provided in Table 3.
Table 3: Private Sector–related Recommendations and Actions Proposed by Task Force for Curbing
Population Growth Rate

Recommendation Broad Actions to Implement the Recommendations

2. Ensure Universal Access to FP/RH Services
ii. All general registered private 2. Enlisting and signing Letter of Understanding (LoU)
sector practitioners and
4. Conduct Training of Trainers (ToT)
hospitals to provide FP
counseling, information and 5. Step down training
services to male & female
clients. 6. Monthly performance report to PWDs [linked to Recommendation 1 (C)]

v. NGOs and Civil Society 2. Partnership mechanism / MoUs between PWDs and CSOs
Organizations to work in close
3. Provision of counseling and/or services by NGOs in underserved and unserved
coordination with provincial
areas.
DOHs & PWDs to extend
FP/RH services to underserved
4. Coordination / Periodic Performance Review
and unserved areas.
3. Finances
iii. Donor financing to NGOs and 1. Federal Government (MoFA and EAD) to mobilize external resources through bi-
private sector organizations lateral, multi-lateral and international community arrangements for NGOs and
involved in FP/RH to be private sector under different modalities including social / commercial marketing
streamlined through an and social franchising
effective coordination
2. EAD to establish a donor consortium for supporting the advancing family planning
mechanism.
agenda
3. Consultative meeting under the chair of Secretary EAD to finalize protocols /
mechanism for supporting Civil Society Organizations

4. Circulation of Instructions from EAD to the concerned quarters

11
Government of Pakistan. 2018. Investing in Sustainable Population Growth: National Symposium on Alarming Population
Growth in Pakistan: Call to Action (Dec 5, 2018). The Ministry of National Health Services, Regulations and Coordination and
LAW AND Justice Commission of Pakistan.

7
 Recommendation Broad Actions to Implement the Recommendations
iv. Corporate Sector to allocate 1. Hold meetings with M/o Finance, FBR and SECP to require compulsory allocation
CSR funds for FP services and of substantial part of CSR funds for family planning.
advocacy.
2. Jointly review and work out modalities of utilization of CSR by the corporate
sector bodies for FP services & advocacy
3. Devise review system and ensure its implementation and reporting on annual
basis
4. Legislation
i. Family Planning & 1. Drafting the FP&RH Rights Bill in consultation with relevant stakeholders and
Reproductive Health (FP&RH) departments including DOH and getting it vetted from Law Division / Department
Rights Bill ensuring mandatory
FP/RH services by all general
health care facilities in public
and private sector.

6. Curriculum and Training

vi. Training to be provided to all 1. Updating National / Provincial Standards and training material on FP&RH to
public & private health care include infusion of a rights-based approach
providers on all modern
2. Training of Trainers of RTIs, RHS-A master training centers and Public Health
contraceptive methods.
Schools of DOH
3. Step down training of the services providers (public & private)
7. Contraceptive Commodity Security
ii. Pooled Procurement model to 1. Holding meeting of Inter-Ministerial Strategic Forum on Health & Population to
be adopted by the Federal & develop consensus on pooled procurement
Provincial Governments 2. Taking up the matter at respective Provincial Task Forces for endorsement
(subject to their consent) to
garner the benefits of economy 3. Finalization of operational modalities
of scale.
iii. Supply Chain Management 1. Develop/improve dashboard at the district / sub-district level showing method
System to be strengthened to wise availability of contraceptives at all service delivery points of public & private
ensure availability of all sectors including CSOs
contraceptives at Service
2. Develop Android app for real time reporting on performance and availability of
Delivery Points.
contraceptives at sub-district offices and SDPs
3. Provide Android tablets at all sub-district offices and service delivery points
including private sector
4. Design & conduct training of supervisors and service providers of public &
private sectors including CSOs;
Source: Government of Pakistan. 2018. Investing in Sustainable Population Growth: National Symposium on Alarming
Population Growth in Pakistan: Call to Action (Dec 5, 2018).

Note: Recommendations and actions are numbered as in the original document.

At the National Symposium on “Alarming Population Growth in Pakistan,” organized on December 5,

2018 under the aegis of the Supreme Court to emphasize the need for swift action on the Task Force’s
recommendations, it was recommended that NGOs and civil society organizations (CSOs) should work
in close coordination with the provincial departments of health and population welfare to extend FP
services to underserved and unserved areas and ensure universal access to FP services. Federal and
provincial governments are responsible for this coordination.

8
Moreover, all the provincial CIPs, population policies, and strategic health roadmaps acknowledge the
need for forming PPPs. Currently, regardless of the approval status of their CIPs, and in consonance
with their provincial population policies, all provinces are committed to scaling up partnerships in
health through contracting mechanisms. In Sindh, the PWD and DoH have identified linkages for
public-private partnerships to reach vulnerable segments of the population, including the poor and
youth, as a specific strategic area.12 Three provinces, including Sindh, Punjab, and Khyber
Pakhtunkhwa (KP), have also passed legislation to support the creation of PPPs under which
administrative units to spearhead PPPs have been established. Collectively, these elements have
created an enabling environment for the government to move in the direction of PPPs.

Approach
The United Nations Population Fund (UNFPA) supported/commissioned the Population Council to work
with a national consultant and federal and provincial governments for developing a framework to guide
PPPs for family planning in the country. The major activities to ensure a full consultation of
stakeholders is outlined below.

• A literature review of relevant best practices in PPPs was conducted. Projects with partnership
mechanisms for FP provision in the country were also studied.

• An orientation meeting was held in Karachi (on October 10, 2018), attended by the Director
General, Population Program Wing, Ministry of National Health Services, Regulations &
Coordination and provincial Secretaries of the Health and Population Welfare departments of the
Punjab, Sindh, Balochistan and Khyber Pakhtunkhwa provinces, as well as representatives of the
Population Council and UNFPA, to develop a plan of action and inception report.

• Provincial and national roundtable consultations were conducted in Peshawar (on November 16,
2018), Lahore (on November 24, 2018), and Quetta (on December 12, 2018), and a final
national consultative meeting was held in Gwadar (on December 18, 2018). Participants included
experts from the public and private sectors, donors, and civil society. More than 25 experts were
present in each of the provincial consultations. The first draft of the framework components was
circulated for comments to all the participants. Their feedback and inputs are incorporated in the
current document.

12 http://pwdsindh.gov.pk/Publications/e-books/CIP%20Sindh-03%2015%2016-final.pdf

9
 Orientation Meeting Provincial selection of
Karachi 20-25 participants PPP Concept Note
shared with
Dates for provincial (Public, Private, NGO, participants
meetings set SMOs, Civil society)

Roundtable
consultations held in
Peshawar, Lahore, and Report on the draft A national meeting on
Quetta to develop frameworks national PPP framework
provincial PPP
frameworks

• Qualitative research: A qualitative study was conducted to obtain insights of private sector service
providers, suppliers, and end-users of FP services about potential public-private partnerships to
improve access to FP services in Pakistan. The study also looked into the proposed roles of the
two sectors and benefits of PPPs to end-users. The findings of this study, which are documented
in this companion report entitled “Improving Access to Family Planning Services through the
Private Sector in Pakistan – A Stakeholder Analysis”, have also been used in developing the
framework.13

Findings from Existing Literature on PPP

A wide literature search was undertaken to better understand the concept and definition of public-
private partnership and identify models relevant to the Pakistan context. Another key objective was to
help in identifying the key levers for success of PPPs and the pitfalls to be avoided.

Definitions – What is a Public-Private Partnership?

In recent years, both the public and private sectors have found mutual benefits in engaging in
partnerships as there is potential for addressing complex problems by leveraging the strengths of each
sector. To begin with, it is important to clarify what we are defining as “public” and “private.”
• The public sector refers to all sectors of the government at different levels, i.e., federal, provincial,
district, municipal, local government and other inter–governmental agencies which deliver public
goods.
• The private sector is much broader: it includes for-profit, commercial or business entities in both
the informal and formal sectors, ranging from small business and micro-enterprises, to
cooperatives and large national and multinational companies, and it also means professional
associations and corporate philanthropic foundations directly funded and/or governed by
business.14 Civil society is also part of the private sector. It includes NGOs, social marketing
organizations (SMOs), faith-based organizations (FBOs), and philanthropic entities.

13
Kamran I., Parveen t., Niazi R., Khan M. and Khan K. 2019. Improving Access to Family Planning Services through the
Private Sector in Pakistan – A Stakeholder Analysis. Islamabad. Population Council.
14
Martens, J. 2007. Multisectoral Partnerships - Future Models of Multilateralism? Dialogue on Globalization and Friedrich
Ebert Stiftung . No. 29, 1-78. Berlin.

10
 • There is no single, internationally accepted definition of what constitutes a public-private
partnership. A broad view taken globally is that a PPP is a long-term contract between a private
party and a government entity for providing a public asset or service in which the private party
bears significant risk and management responsibility, and remuneration is linked to
performance.
The United Nations defines partnerships as voluntary and collaborative relationships between various
groups, state and non-state actors, in which all participants agree to work together to achieve a
common purpose or undertake a specific task and to share risks and responsibilities and resources.15
The Initiative on Public–Private Partnerships for Health (IPPPH)16 points out that the term “partnership”
has been used loosely to include communication, consultation, coordination, and collaboration, and
cautions that simply calling a venture a partnership does not mean that there is joint decision-making.
The terminology is further expounded to describe PPPs as “a continuum of loose to tight arrangements
that combine different skills and resources from institutions in the public and private sectors with the
aim of effectively tackling socio-economic problems like education and health that persist in the face
of independent actors.” 17
The World Health Organization (WHO) describes public–private partnerships for health as: “public
sector programmes with private sector participation”—a vague definition that allows for many shapes
and sizes of PPPs, and implies that a government partner sits at one end of the table, setting the
priorities and rules under which private organizations operate.
Strengthening Health Outcomes through the Private Sector (SHOPS), a flagship initiative of the United
States Agency for International Development (USAID), defines a PPP in health as any formal
collaboration between the public sector at any level (national/local governments, international donor
agencies, bilateral government donors) and the non-public sector (commercial, nonprofit, service
providers) in order to jointly regulate, finance, or implement the delivery of health services, products,
equipment, research, communication, or education.18
According to yet another definition in global health programing, PPPs represent a public–private mixed
(PPM) approach to health care delivery which involves an integrated system of public health care
providers and for-profit, not-for-profit, and/or informal providers.19
Although definitions vary, the objective is assumed to be use of private sector advantages to meet
public health goals through implementation of policies that can increase coverage and improve quality
and cost effectiveness of basic health services. For this to happen, it is essential for public policy to
define the division of labor and identify the sector responsible for specific segments of the population.
To make such a division possible, the public sector should avoid provision of free or heavily subsidized
services to clients who can pay, so that the private sector does not have to compete against it for these
clients.

15
Ibid.
16 www. Ippph.org
17
Nantulya, V.M. (2008) Getting diagnostics into countries. Bringing products to markets. Health partnerships review.
Global Forum for Health Research 68-72.
18 Jeffrey Barnes. 2011. Designing Public-Private Partnership in Health. Bethesda, MD: SHOPS Project, Abt Associates.
19 Kaboru, B. B. (2012). Uncovering the potential of private providers’ involvement in health to strengthen comprehensive
health systems: A discussion paper. Perspectives in Public Health 132(5), 245–252.

11
The two main categories representing service provision are, first, service delivery and, second, facility
management. The private sector can be engaged in either through a contract. Contracts can then
balance out the efficiency and equity considerations.

Existing PPP Models in Pakistan

In Pakistan, the government has some experience—more so in the recent past—of partnering with the
private sector for expansion of infrastructure and public services in sectors other than RH, such as
energy, transport, roads, and more recently, urban waste management. However, no formal framework
currently exists to guide Pakistan’s mixed and fragmented health system in engaging the private sector
for much-needed participation in FP service provision.
There are, on the other hand, many examples of the government supporting private sector institutions
in their efforts to promote FP in Pakistan. For example, through registration of GSM’s condom brand
Sathi, and subsequent renewals of its trademark, the earlier entity of the Ministry of Population
Welfare enabled GSM to promote use of condoms, which are now the most popular method of family
planning in Pakistan and constitutes 37 percent (9.2 out of 25.0 percentage points) of mCPR in the
country.
Moreover, there are some prominently known primary health care initiatives that are based on the
PPM approach. Most notable among these is the People’s Primary Health Initiative (PPHI), a successful
PPP management contracting experience that began as the President’s Initiative in 2007, when
management contracts for basic health units (BHUs) were given to Pakistan Rural Support Program
(PRSP) in 69 districts across the country, starting with Rahim Yar Khan. Memoranda of Understanding
(MoUs) were signed between district governments and the PRSP.20 The initiative was registered as
a nonprofit company under section 42 of the Companies Ordinance 1984 and a supervisory Board of
Directors was established to take the initiative forward.21
In Sindh, the PPHI collaboration is functioning smoothly and now a similar relationship is being
developed in Balochistan whereby PPHI will work with the PWD. The budget is given as a one-line item
to PPHI. Currently, 1,140 out of 1,192 primary health care facilities are being managed across Sindh
(except in Karachi and Nawabshah) through this publicly financed model. Thus far, 311 BHUs have
been upgraded into “BHU Plus” units, which remain open round-the-clock.22
Third-party evaluation of the PPHI shows higher utilization of the contracted BHUs in terms of volume
of outpatient attendance as compared to pre-partnership performance. There has also been improved
cleanliness and maintenance, higher staff presence, and higher patient satisfaction.23

20 Ravindran, T. K. S. 2010. Privatization in reproductive health services in Pakistan: Three case studies. Reproductive
Health Matters 18(36):13-24.
21 https://www.healthynewbornnetwork.org/partner/peoples-primary-healthcare-initiative-pphi-sindh/

22 ibid

23 Martinez, J., Pearson, M., England, R., Donoghue, M., Lucas, H., Khan, M.S., Haq, B., Hayat, M., Moinuddin Q. H.,

Rehman, A. and Jogezai, M. 2010. Third-party evaluation of the PPHI in Pakistan. DFID-HLSP, Technical Resource Facility
and SOSEC: Islamabad.

12
As shown in Figure 5, in the last five years, family planning use has increased with the mCPR among
MWRA in rural Sindh rising by more than 3 percentage points (from 17.4 percent in 2012-13 to 20.4
percent in 2017-18), which seems to be the result of the public-private partnership programs.
Figure 5: Increase in contraceptive use in rural Sindh among MWRA

100

80

60

40
17.4 21.4 17.1 20.4
20
1 2.8
0
CPR mCPR LARCs (IUD+Implant)

2012-13 2017-18

Source: PDHS 2012-13 and 2017-18

Another private organization that has partnered with the public sector is HANDS, which has evolved in
37 years as one of the larger non-profit organizations of the country with an integrated development
model and disaster management expertise. Under its “Adopt a Hospital” initiative, HANDS has
executed management contracts with the Department of Health. Under its Marvi Programme,
supported by the Bill and Melinda Gates Foundation (BMGF), the organization has shown that access
to health services can be improved in the most remote communities that are not served by LHWs by
training local uneducated women to provide basic family planning materials and services, and enabling
them to provide this service on a commercial yet affordable basis, provided there is a back-up
organization (NGO or private entity) to ensure contraceptive supply and resolve other issues. Each
community health worker (“Marvi”) covers 100 to 150 households. By 2016, there were 945 Marvis
in 21 districts across Pakistan. In target areas of the program in Sindh, CPR has increased from 9
percent to 27 percent in three years; while not a PPP, the program has demonstrated that the CPR
can be raised quickly when the private sector replicates successful approaches of the public sector.
Recently, the Sindh and KP governments have also signed MoUs with the HANDS for free provision of
contraceptives in Sindh and in district Mansehra, KP, respectively.
Similarly, Aman Foundation, under its Sukh initiative, has also piloted some public-private partnership
programs in peri-urban and rural Sindh. Most relevant is the training and subsidization of 200 LHWs
to enable them to administer the first dose of injectable contraceptives.24
Integrated Health Services (IHS) is another NGO working to increase access by integrating health
services. IHS has a contract with DoH Sindh since 2016 to operate 111 facilities (6 Taluka hospitals
and 104 Rural Health Centers) in 21 districts of Sindh. Increased turnover of patients is reported in
these revamped 24/7 facilities where services are free.
The Employees Social Security Institutions (ESSI) is another PPP model in Pakistan. It shares the
service provision and financing role with the private sector but as the management is quasi-
governmental, it could be considered a subsidiary body of the government.

24 Najmi, H., Ahmed, H., Halepota, G.M., Fatima, R., Yaqoob, A., Latif, A., Ahmad, W. and Khursheed, A. 2018. Community-
based integrated approach to changing women's family planning behaviour in Pakistan, 2014–2016. Public Health
Action, 8(2), pp.85-90.

13
Social franchising initiatives have helped to build a network of facilities providing FP services and
following consistent standards to ensure quality of care. The facilities are branded so that they are
easily identifiable. Among the largest SMOs, Greenstar Social Marketing and Franchising is present in
the country since 1995 and works on both the supply and demand side by strengthening private
providers and creating demand through behavior change communications through all media. There is
scope for increased public sector involvement in social franchising so as to bring networks of
franchised private providers to scale for a broader health impact.
Clinical Franchising There are examples of government mechanisms that can guide the development
and expansion of franchises, for instance, a pilot tested by PWD Punjab (2016-18) in DG Khan, Jhang,
Layyah, Rahim Yar Khan, and Khushab districts.25 It was anticipated that if every service provider
partnering with PWD provides family planning services to 10-12 new clients per month, approximately
45,000-55,000 new family planning clients will be served in two years in these districts. The pilot test
was executed with the assistance of NGOs having well-established linkages with private practitioners
and service providers in their respective districts.
Voucher schemes have also been tested as small projects by NGOs such as Marie Stopes Society
(MSS) and GSM with donor funding and these helped increase uptake of LARCs. However,
implementing organizations have not had resources to continue or scale up. A study of the cost-
effectiveness of implementation of Marie Stopes’ Suraj social franchise in 29 districts in Sindh and 3
districts in Punjab between October 2013 and June 2016 found the cost per additional CYP to be
$4.27 compared to business-as-usual from the perspective of the funder.26 This compares the results
to other interventions with similar objectives and it found that the voucher scheme was cost-effective
and affordable, having the potential to be scaled up provided certain structured changes were
incorporated.27

Table 5: Major Contributors of Couple Years Protection (CYP) – Reported in PBS 2016-17

Outlet % of Total CYPs

PWD (Family Welfare Centers) 20.3
DoH (Lady Health Workers) 17.0
DoH (Health Facilities) 15.6
Greenstar Social Marketing 13.3
Marie Stopes Society 11.1
Rahnuma-Family Planning Association of Pakistan 10.7
RHS (Reproductive Health Services – PWD) 8.6
Others 3.4
National 100
Source: Pakistan Bureau of Statistics 2016-17

25
https://pwd.punjab.gov.pk/system/files/Initiatives_0.pdf
26 Broughton, E. I., Hameed, W., Gul, X., Sarfraz, S., Baig, I. Y., & Villanueva, M. (2017). Cost-Effectiveness of a Family Planning
Voucher Program in Rural Pakistan. Front. Public Health 5:227. doi: 10.3389/fpubh.2017.00227.
27
Azmat, S. K., Ali, M., Hameed, W. and Awan, M. A. 2018. Assessing family planning service quality and user experiences
in social franchising programme–case studies from two rural districts in Pakistan. Journal of Ayub Medical College
Abbottabad, 30(2), 187-197.

14
Findings from Provincial Consultations
Interest in Forging PPPs for FP
During the consultative meetings, all provincial participants confirmed that the challenge of reaching
the FP2020 target of 6.7 million additional users of contraception will require enhanced resources,
raising the per capita expenditure to the FP2020 commitment of $2.50, and a programmatic refocus
to address the service needs of couples by introducing long-acting reversible methods, and policy
reforms such as task sharing. They also agreed that the government alone cannot deliver fully on this
commitment.
Participants agreed that the root cause of Pakistan’s poor health indicators is an underfunded health
system, with annual expenditure of only $12-13 per capita. The resulting considerable out-of-pocket
spending on health has encouraged the private health sector to flourish, mostly providing curative
services. If public finances can be used as an incentive to harness this sector for essential services to
low-income populations, then chances of improving health indicators can be raised. Participants
shared that there is a growing realization in the government of the significance of the private sector in
contributing towards delivery of infrastructure and social services. This is manifested in recent
legislative, policy, and institutional measures that provinces have undertaken in this respect.
There was a consensus across the provinces on the need for having PPPs to increase access to FP
services, and to integrate these services with RH services and the MNCH program. Representatives
from Punjab, KP and Balochistan emphasized the dearth of manpower in the public health sector and
recommended that partnerships be forged to outsource facilities to private sector partners. They felt
that PPPs could enable provision of evening services at PWD centers and in the MNCH departments
of public sector hospitals. In Balochistan, the biggest issue is absenteeism and how to motivate
government employees. Private partners may be involved to help resolve this issue. KP and Punjab
expressed an interest in expanding provider networks for family planning services by increasing the
number of family planning clinics and reaching out to underserved communities through private sector
community-based distribution systems and SMOs.
During the consultative meeting in Punjab, representatives of the PPP Unit/cell said they were willing
to support health sector projects with PPP contracts and mechanisms and they already have some
experience in giving management contracts for government hospitals to the private sector, as in the
case of Pakpattan Hospital. However, during an in-depth interview in Sindh, the government
representative was of the view that the province has a functioning model for PPPs in rural areas in the
shape of PPHI, and that post-18th Amendment, federal technical assistance is not required. The
representative pointed out that PPHI already offers integrated services in Sindh, including MNCH, FP,
immunization, nutrition, and general outpatient clinics for eye and dental care, as well as vaccination
for dog bites, snake bites, etc.

Institutional Readiness for PPPs

Punjab, Sindh and KP have passed legislation to govern public-private partnerships, known in each
province as the Public Private Partnership Act 2014, and each province has also established a PPP
Cell under this legislation. The PPP cells/units in Punjab and KP are embedded in the Planning &
Development Department while Sindh’s PPP unit is housed within the Finance Division. The PPP cell
is responsible for identifying partnership projects, carrying out initial screening and feasibility studies,
and monitoring and coordination throughout the project life.

15
Since the 18th Amendment, which resulted in the devolution of social and infrastructural sectors, the
provincial governments have developed PPP projects with wider application, for example in the
transport, waste management, and energy sectors. However, there are very few examples of formal
PPPs in the health sector, and those that exist mostly have a narrow focus on delivering infrastructural
services. As mentioned earlier, the People Primary Health Initiative is deemed to be working well in
Sindh, as are some other hospital management contracts, but these are yet to be evaluated externally.

Suggested Contours of PPPs for FP

Six partnership areas were identified, including service delivery and integration of services;
governance; planning; implementation; human resource and government capacity building; and
finances and commodity security. These blocks are described in Table 6.
There was agreement on the following:
• It is important for provinces to be clear about the specific issues that the partnerships would
address, where and why investment is needed, how partnerships would be implemented, and by
what means the performance would be monitored.
• Intermediary partners should be identified to act as an interface between the public and private
sectors. These intermediaries could be NGOs, SMOs, academic groups, or professional
associations.
• With regard to governance, government must be the lead organization advancing PPP efforts for
FP, with technical, financial, and operational management assigned to both the public and private
sectors. Contractual mechanisms should be established to help define the roles and
responsibilities of each sector.
• Contractual arrangements should be duly notified and implementing committees formed, such as
management and quality assurance committees. Management committees would monitor
projects from the beginning, keeping track of all aspects agreed in the PPP contract. A regular
monitoring mechanism should be put in place while periodic evaluation of the implementation
work should be carried out in compliance with regulations through third-party audits.
Overall planning should be carried out as a joint effort by the government and private partners, with a
need-based approach and a focus on the requirements of each region. The process should be based
on solicited proposals. All PPPs should be initially tested as pilots, with potential future formalization
and upscale.

16
Table 6: Partnership Building Blocks and Common Elements Identified in Provincial Consultations

Partnership Building Description

Block

Service delivery & Family planning service expansion by engaging private sector to offer services under
services integration the umbrella of mother and child health from all public and private sector facilities.
Public sector leadership; utilize the PPP Act and Units for awarding contracts and
managing public finances; govern through committees with public and private sector
Governance representation.
Establish regulations and enforce standards.
PPP to be set up through solicited projects, i.e., identified by government with support
from a civil society or private sector consulting firm, which serves as an interface
partner.
Planning
Unsolicited proposals from private sector to be submitted to government for approval.
Participation of different stakeholder groups, as intermediaries with defined roles,
responsibilities and capacities, to assist in PPP management.
Establish an Implementation Committee for strategic oversight and overall monitoring.
Current ad hoc models in use can be scaled up. E.g., private sector can be engaged to
introduce evening FP services at PWD centers
MCH centers of public sector hospitals can be outsourced to private parties through
Implementation management contracts and they can work for FP promotion and service delivery
In Punjab, there is interest in the “Build, Upgrade and Transfer” or “Build-on-operate”
model, under which private parties can build model MCH hospitals with initial support
from the government (grant of land for construction of facility)

Human resource Hiring contractual employees from private sector

skills and
government
capacity
Finances and Private pharmaceutical companies to lower profit margins on contraceptive products
commodity security for bulk purchase by government

17
Conceptual Framework for PPPs for Family Planning
In this section, we present a conceptual approach that can help guide PPP planning and
implementation. The framework we are proposing is generic and can be refined according to provincial
requirements. The framework is also modular and can be modified in response to specific challenges.
In the early stages of setting up partnerships, emphasis should be on creating an enabling
environment for PPPs to flourish, and creating and promoting opportunities for partnerships. In some
provinces, PPPs in health have already been implemented on an ad hoc basis; these too can be
strengthened through use of this framework.

Step 1: A SWOT Analysis – What the Public and Private Sectors

Can Offer
The main basis on which the public and private sectors can forge strong partnerships is the recognition
that both sectors offer complementary strengths as well as limitations. Working together, the two
sectors can address issues by utilizing their respective strengths, avoiding or compensating for one
another’s weaknesses, and capturing opportunities available to them. To identify what the public and
private sector can offer in Pakistan’s context, we conducted a SWOT (strengths, weaknesses,
opportunities and threats) analysis, which is summarized in Figure 6.
Figure 6: Public-Private Partnership - Illustration of SWOT Analysis

Public Sector Public Sector

• Affordable services • Irregular supplies
• Widespread physical infrastructure at • Poor quality of services
various levels—primary, secondary, • Overcrowded, especially at large facilities
and tertiary • Deficiency of female providers
•
Weaknesses

• Training capacity Inflexible rules and regulations

Strengths

• Technical competency • Ban on recruitment

• Demotivated staff
• Non-functional equipment
Private Sector Private Sector
• Flexible • Poorly regulated fee for services
• Hiring/firing is easier • Focus on profit
• Based on efficient business models • Varying standard of services
Higher number of providers • Less focus on preventive, promotive, and
• Deeper penetration makes for non-lucrative services
greater efficiency and effectiveness

Public Sector Public Sector

• Legal cover through PPP Act passed • Weak understanding of PPP
by the provinces • Possibility of abdication of responsibility
•
Opportunities

Chief Justice judgment encouraging by public sector

PPP • Mistrust of private sector
Threats

Private Sector Private Sector

• Willingness to work with public sector • No maintenance of standards
• Realize the potential growth of their • Not respecting the ethics of voluntary FP
market as unmet need for FP is high service provision
(a market that can be easily tapped) • Pushing for single “lucrative methods”
• Overemphasis on profit

18
Step 2: Potential Areas for Developing PPPs for Family Planning
The overarching outcome of the proposed framework for PPPs for FP is to improve the quality of
existing services and enhance access, efficiency, and future sustainability. Based on a SWOT analysis,
outlined above, we have identified four areas where partnerships can be developed, which are shown
in Figure 7.
Given the private sector’s vast coverage of services and large number of providers, often extending to
areas where public sector facilities are not present, PPP schemes can help reduce human resource
deficiencies and help reach out to the marginalized. Joint procurement of equipment and supplies can
reduce procurement and logistic costs, helping to enhance economies of scale. Private sector
management is based on efficiency and introducing a similar culture in public sector entities can
reduce inefficiency and wastage.
Figure 7: Potential areas of Public-Private Partnership Framework

Improve
Management &
Enhance
Effectiveness

PPP

Meet Human Improve Equity &

Quality,
Resource PPP Gender Equality
Deficiency Access & PPP (improving access
Sustainability to the poor)

PPP

Improve
Efficiency by
attaining
Economies
of Scale

19
Step 3: Creating the Enabling Environment for PPP
The following specific measures are needed to create an enabling environment for private sector
participation in improving FP outcomes:
1. Create a broad-based consensus on the framework through provincial consensus building
workshops.
2. Establish supportive policy and legislative frameworks to encourage private sector participation.
This is the first and foremost step that will ensure that partnership are not established on an ad
hoc basis.
3. Create institutional mechanisms for effective interaction and coordination with the private
sector. The literature points to the utility of creating specialized PPP cell or nodes in the public
sector to help foster partnership.
4. Identify an institutional funding mechanism, i.e., provision of funds through provincial ADP
schemes, or soliciting PSD funding, and also explore donor interests.
5. Ensure that agreements between public and private sector entities take the form of formal
written contracts rather than informal or nonbinding agreements such as MoUs. The contracts
should lay out specific deliverables to be contributed by each partner and also clearly spell out
penalties and rewards for each partner.
6. Accommodate the profit motive of the private for-profit sector in partnerships.
7. Increase capacity and skills required by public and private sectors for undertaking partnership
initiatives in health. Staff capacity in the PPP cell/node/units must be developed through
trainings to deal with legal, operational, and managerial requirements for successfully
implementing the partnership. The PPP unit should have the commercial and legal skills needed
to be a key source of support for the public sector in developing and financing projects.
8. Work closely with potential private sector partners to build their trust and willingness to be
involved in partnership initiatives for improving outcomes, aiming for a win-win scenario for both
partners.
9. Establish implementation oversight committees.
10. Develop consensus on a third-party evaluation mechanism. The generic components of such a
mechanism are shown in Figure 9.

Proposed Public-Private Partnership Framework

Our proposed framework for PPPs for FP as based on the above concepts and responsive to the needs
of Pakistan as expressed by our stakeholders is summarized in Figure 8 and described on the following
pages. It incorporates three distinct models that have been individually tested in Pakistan and globally,
and found to be feasible in our setting. However, the scale of their implementation has been generally
limited or they have been executed as isolated initiatives addressing one issue or one segment of the
population. The proposed framework advocates execution of a combination of the three models
described in the literature as the balanced model, socially based model, and market based model28
as a comprehensive initiative by the government to address the needs of all segments of users. The
three models bring together the private (commercial) and social sectors together.

28
Jeffrey Barnes. 2011. Designing Public-Private Partnership in Health. Bethesda, MD: SHOPS Project, Abt Associates.

20
Figure 8: Proposed Public-Private Partnership Framework

PPP Framework for Improving Access to and Quality of FP Services

This framework is a combination of three PPP models with proposed different pathways that need to be adopted with a holistic
approach to be able to achieve overarching outcomes

Overarching Outcome Efficiency, Sustainability, Equity

Models Balanced PPP model Socially based model Market-based model

Social franchising and Contracting out services Accreditation of private

Tapping Corporate Social Working with Pharmaceutical
Pathway voucher schemes/ /management to private facilities providing FP
Responsibility (CSR) industry / distributors
Social marketing providers/NGOs services

Corporate sector involvement in Achieving efficiency through

Outcome Expanding physical access, ensuring equity delivering social goods ensuring economies of scale (Bulk order
future sustainability purchases)

Government Government Government

Partnership
NGOs / SMOs / Private providers Corporate sector Local pharmaceuticals

Govt. contribution: Provide logistics support, FP products, physical space, Govt. contribution:
Govt. contribution:
trainings, technical supervision, and quality assurance through accreditation/ Provide health education materials
licensing by Health Care Commission. Purchase indigenous
and contraceptives.
contraceptive products made
Private sector contribution: Offer subsidized FP services including referrals Corporate sector contribution: available at all facilities
(could also follow the clinic sahulat model of providers holding free medical
camps on specific days); marketing contraceptives, especially new methods Local pharmaceuticals:
As a part of CSR, allocate time for
Contribution such as implants, SDM, or Sayana Press to reach rural communities. counselling sessions for workers
Providers offer free FP services to the poor by redeeming vouchers. Provide subsidized products
and provide them free
to govt. and share logistics
contraceptives, purchased from
the government. Sponsor
(The low profit margin can be
advertisements to promote family
offset by increase in sales)
planning along with their products.

21
1. The balanced model brings together the social and commercial sectors. It is dependent upon
commercial profits and social investments. The first aspect we propose under balanced PPP model is
Social Franchising. The social franchiser (intermediary agency) utilizes public or donor funds to provide
trainings; distribute commodities or products; and offer quality services through agreements with
franchisees (commercial health providers) in a prescribed manner over a specified period. This type
of partnership is effective for immediate improvement for quality of and access to services and for
facility development.
In the framework, we propose a model of social franchising in which the public sector supports
interested private providers in far-flung areas in FP service provision by providing trainings as well as
FP products and technical supervision, while the private providers offer subsidized services. The public
sector can train private doctors and LHVs in a range of family planning services, including FP
counseling; insertion of intrauterine device (IUDs), postpartum intrauterine contraceptive device
(PPIUCDs), and implants; and manual vacuum aspiration (MVA) services. Providers meeting quality
standards can be branded and allowed to use a predefined franchise logo. Similarly, private sector
MNCH providers can be recruited to provide postpartum FP services. This approach was tried on a
limited scale in Punjab in DG Khan, Jhang, Layyah, Rahim Yar Khan, and Khushab districts.
2. We also propose adding to the franchising model a Voucher Scheme for beneficiaries of the Benazir
Income Support Program (BISP). Access to the franchised providers can be enhanced through the
voucher scheme in selected areas where there is higher concentration of BISP beneficiaries. The
government can issue vouchers to the poor to avail private sector services managed by a private
sector voucher management agency. The voucher will cover the cost of travel to public sector facilities
as well as private providers’ fees, which will be predetermined.
3. We recommend expanding the outreach of existing SMOs to penetrate to the rural areas and provide
contraceptives, especially newer products, at shops, pharmacies, and clinics of private providers.
SMOs will also work with the government to launch behavior change communication programs
leveraging their strong marketing capabilities.
4. Another aspect of balanced model is “Contracting Out” whereby the private sector offers a defined
set of health care services in return for a pre-negotiated remuneration. In order to enhance the
capacity of the existing public sector facilities, especially those that are understaffed, we propose in
the framework that, applying the balanced model, the government contract out services to private
providers, for example, unemployed Lady Health Visitors or Family Welfare Workers (FWWs), who can
set up their clinics within the government facilities and provide subsidized services to FP clients in
the evening hours, when the facilities are otherwise closed. This concept was suggested by senior
government officials from KP during the provincial meetings. In addition, in order to reach
underserved areas, the government should contract out to an NGO to provide FP services through
community workers on the lines of the Marvi worker model practiced in Sindh, or outsource its Mobile
Service Units to serve marginalized populations in hard-to-reach areas.
5. Another component proposed within this model is for the government to bring on board the private
sector by making provision of affordable FP services a mandatory requirement for accreditation and
licensing by the provincial health care commissions.
6. The socially balanced model aims to improve public health through engagement of the corporate
sector. A typical example of the model is corporate social responsibility (CSR), in which the commercial
sector helps to expand social welfare activities led by the government. The organized corporate sector

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 and other business and industry associations can play an increasingly significant role in such efforts
as advocacy, funding of NGOs for innovative interventions, and allowing workplace FP service
provision.
We propose that the government work with large corporate sector establishments requisitioning them
to make family planning provision mandatory through all their health care facilities. Corporate sector
entities may also be requested to allocate time for their employees to attend special FP counselling
sessions and participate in clinics organized by the PWD/Health department at the workplace. Public
corporations and other government departments should be involved in such initiatives as well, e.g.,
Pakistan International Airlines (PIA), Oil and Gas Development Company Limited (OGDCL), Pakistan
Railways, Pakistan Steel, Pakistan State Oil (PSO), etc.
The cost of the clinic, including price of contraceptives provided during the clinic, may be borne by the
commercial enterprise. Furthermore, the corporate sector can be engaged to air public service
messages about family planning on the electronic media as well as the print media. These activities
can be funded by corporate concerns from their CSR budgets; while they will not earn them profits,
they will accrue social returns, i.e., a better public image as a responsible corporate body. In addition,
having employees who are able to plan families could, in the long run, contribute to better health
among their staff, reduced staff health expenses, and fewer maternity/paternity leaves, thereby
improving worker productivity and lowering costs per worker.
7. In the market-based model, the commercial sector is encouraged to accept a tradeoff of lower profit
on sale of contraceptives at the start of the initiative in exchange for greater growth and profit in the
future. The commercial for-profit entity partners with the public sector with the objective of enhancing
social impact. The model is sustained through profit generation. In this framework, we propose
bringing on board the local pharmaceutical industry, such as ZAFA, Bayer, and others, to lower the
profit margins on their contraceptive products, allowing bulk purchase of their products by the
government for all its departments. The shortfall in price can be offset by the expansion of the market
so the pharmaceutical concerns still make profits. New products such as implants and Sayana Press
can in this way be introduced into the public sector.

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Operationalizing the PPP Framework
Step 1 – Legislation: Many countries introduce PPP legislation as a more binding form of commitment
to a PPP framework. National policies control and describe what should be done for approval,
procurement and regulation of commodities, their promotion in the mass media, their sales and
distribution or delivery of services. Policies also determine the amount of government financial
resources that go to FP provision.

In Pakistan, three provinces have a dedicated PPP law which is a component of broader public financial
management law. Specific details with regard to PPP for FP need to be elaborated. A clear policy, legal
and regulatory framework should be established as PPPs depend heavily on contracts that are
effective and enforceable. Where possible, legal terms and approaches familiar to the private sector
should be employed. Moreover, laws and regulations as well as policy directives should be put in place
to facilitate the partnership process as part of a total market approach.
Step 2 – PPP Forums: This should be followed by creation of joint PPP forums to facilitate the
development of strategic operational plans by the PPP units/cells and roadmaps for implementation.
The strategic plan identifies the roadmap that guides implementation. Importantly, a PPP cell or unit
in the planning and development department should develop the operational plan that includes
guidelines, staffing and capacity strengthening requirements.
It should notify a PPP Task Force with membership from public and private sectors including NGOs,
development partners, and academic and professional societies’ representatives, which should have
quarterly meetings to support the work of promoting PPPs, overcoming bottlenecks, and increasing
transparency and accountability. The task force can also develop joint proposals for receiving funding
from global financial facilities.
Step 3 – New Financial arrangements: Financial plans should be drawn up to demonstrate high-level
political support, to indicate the potential flow of future projects, and to explain how projects fit
together within the context of provincial and national plans.
Step 4 – Manual development: To ensure discipline in all these processes, a detailed PPP Manual
must be developed that clearly outlines the standards that ensure that clients obtaining services from
the private sector are making fully free and informed decisions.
Step 5 – Supply supporting materials: Guidance materials, such as manuals, and other tools to
formalize PPP procedures should be developed to supplement policy statements or legislation, as a
codification of good practice.

Timelines for Implementation of the Framework

The timelines are broken down into four logical phases of inception, development, implementation,
and mainstreaming and review, as follows:
➢ Inception Phase – within 6 months
➢ Development Phase – within one year
➢ Implementing Phase – within 2-3 years
➢ Mainstreaming & Review Phase – 3rd year onwards.

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 • The development phase will entail finalization and approval of all proposed instruments
necessary for creating supportive policy and legislative frameworks for engaging the
private sector. In the implementation phase, proposed activities will be carried out as per
the roadmap, having stipulated timelines and targets.
• An evaluation is proposed at the end to take stock of implementation. This will help in
understanding challenges faced, documenting lessons for further improvement, and
proposing a set of recommendations for a revised strategy. In essence, the strategy will
seek to sustain an enabling environment for private sector contribution and engagement
in improving FP outcomes in each province.
• The importance of having a competent PPP unit that is staffed with highly qualified
individuals able to work across government departments cannot be overemphasized. If a
successful PPP program is to be delivered, both project management and rapid monitoring
mechanisms are critical.

PPP Framework Evaluation Model

Once the PPP framework has been implemented, a strong and robust evaluation should be
designed, broadly following the steps shown in Figure 9.
Figure 9: PPP Framework Evaluation Model

EFFECTIVENESS
• Clarity on objectives and outcomes and their measurability
• Achievement of objectives and outcomes
• Clarity on service provision
• Payment mechanism
• Scalability of the model

EFFICIENCY EQUITY
• Cost efficiency and value for money analysis • Benefit to the targeted groups, i.e., the poor
• Compare with other models and options and poorer, marginalized
• Affordability • Client responsiveness
• Cost of development and delivery of the model • Use of public subsidy
• Service utilization

FINANCIAL MANAGEMENT AND SUSTAINABILITY

• Financial management in line with standards
• Financial and programme audit with standards
• Financial viability
• Economic return to non-state partner
• Financial risks and their management
• Financial capability of non-state providers
• Interest of non-state sector to work with state

Source: Adapted and modified from KPMG. The Emerging Role of PPP in the Indian Health Sector. Policy Paper

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Conclusions
As the Supreme Court recommendations (2.2 & 2.5) state the inclusion of expanding private sector
involvement with earmarked funds, the provincial governments must take the leap and make the
private sector a key partner to support them in achieving universal health coverage, the FP2020 goals,
the SDGs, and other public health commitments made by Pakistan for improving the wellbeing of
people.
The time is ripe for taking forward the conceptual framework and roadmap presented in this report,
and for the provincial governments to develop a blueprint for strong, sustainable, and effective PPPs.
Legally binding alliances between the public, private, commercial, and NGO sectors can help address
the unmet need for FP and basic health services. This could make access more equitable by reaching
populations that are vulnerable and underserved, both geographically and from a demographic
perspective. A quick win strategy proposed here is to adapt existing examples of PPPs in the country
and in neighboring countries, with formulation of relevant guidelines to ensure discipline in the
partnership projects.
Given the public-private market shares (existing and potential) for health services and products, and
consumer preferences, there are various roles and responsibilities for both sectors. PPPs provide
opportunities to capitalize on strengths, maximize the use of existing capacity, create competition,
achieve economies of scale, extend service delivery networks, reach the poor, and mobilize additional
resources. All endeavors need the support of favorable policies, open dialogue, and resources.

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Annexures
Annex - 1 Feedback from provincial consultative meetings for
developing PPP framework
Balochistan
public-private Partnership • PPP for FP is a new concept in Balochistan.
for FP through a provincial • The partnership will be established through a legal contract between public and private
PPP Law and process sector partners with clearly defined roles and responsibilities of each sector.
• There is no current PPP Act or system in the province. This will be rectified with
advocacy.
Objectives of PPP The PP partnership will aim to contribute towards achieving Balochistan FP 2020 goals of:
universal access to safe and quality reproductive health/family planning services by 2020,
increase CPR and in mCPR
Service delivery & The PPP will allow private sector including pharmacies and NGOs & SMOs through a ‘pay for
Integration performance’ contract for:
• investment in family health services MNCH and family planning targeting urban slums and
rural communities;
• expansion of networks for family planning service delivery points by reaching out to
unreached communities with community based distribution and social marketing
systems;
Governance • The Population Welfare Department will be the focal organization advancing family
planning efforts in Balochistan and overall leadership will be with the Government
• Technical, financial, implementation and operational leadership will be assigned to both
public and private sectors.
• Sector leaders will be responsible for deliverables of their areas
Planning • The planning will be done by the government and the partners jointly, keeping in view
the need-based approach and requirement of that area.
• Contract will be signed between public and private partners and roles and
responsibilities of each partner will be clearly defined
• The management committee should monitor projects from start, keeping track of all
aspects agreed in the PPP contract.
Implementation • Each partner will participate in the implementation according to the roles and
responsibilities agreed in the contract
• A mechanism will be developed for regular monitoring and periodic evaluation of the
implementation work by implementing partners
• Compliance of laws and regulations will be checked by a third-party audit
Human Resource • Policies for task shifting will be formulated and providers will be trained accordingly to
ensure quality
• Private sector will be assigned to fill the gap where facilities and structures are available
but the government is not able to provide qualified and capable persons for service
delivery
Finances & Commodities • The provincial government will allocate budgets for each year
• Other sources of finances including donors and development partners; UN
agency contribution
• Soft loans from international financial institutions and tax exemption from government
for the commodities can also be tried to arrange needed resources.

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Khyber Paktunkhwa
public-private • The partnership will be established through a legal contract between public and private sector
Partnership for FP partners with clearly defined roles and responsibilities of each sector using the existing PPP
through the system in the province, which has thus far been used for other sectors such as roads e.g.: Chitral
current PPP Law expressway
and process • No request has yet been put forward by PWD for PPP to the legal PPP unit or node for
assistance.
Objectives of PPP The PP partnership will aim to contribute towards achieving KP goals of :
• universal access to safe and quality reproductive health/family planning services by 2020.
• increase Contraceptive Prevalence Rate (CPR) to 42percent by 2020.
• raise modern CPR from existing level to 28percent by 2020.
• reduce unmet need for family planning to 15 percent by 2020.
Service delivery & The PP partnership will allow private sector and NGOs (Social franchising and social marketing
areas of service organizations and pharmacies) through a ‘pay for performance’ contract for
Integration • investment in family health and family planning targeting urban slums and rural communities;
• expansion of networks for family planning services by increasing the number of family planning
clinics and reaching out to unreached communities with community based distribution and
social marketing systems;
• undertaking operations research activities in search of proven innovative methodologies for
service delivery; and
• Introduction of gender specific career counseling within the framework of existing counseling
services.
Governance • The KP Population Welfare Department will be the focal organization advancing family planning
efforts in KP and overall leadership will be with the Government
• Technical, financial, implementation and operational leadership will be assigned to both public
and private sectors.
• Sector leaders will be responsible for deliverables of their areas
• Governance will be informed through two notified committees, for example: Management and
Quality assurance committees
Planning • The planning will be done by the government and the partners jointly, keeping in view the need-
based approach and requirement of that area.
• Contract will be signed between public and private partners and roles and responsibilities of
responsibility of each partner will be clearly defined
• The management committee should monitor projects from start, keeping track of all aspects
agreed in the PPP contract.
Implementation • Each partner will participate in the implementation according to the roles and responsibilities
agreed in the contract
• A mechanism will be developed for regular monitoring and periodic evaluation of the
implementation work by implementing partners
• Compliance of laws and regulations will be checked by a third-party audit
Human Resource • Policies for task shifting will be formulated and providers will be trained accordingly to ensure
quality
• Private sector will be assigned to fill the gap where facilities and structures are available but the
government is not able to provide qualified and capable persons for service delivery
• Capacity building: Contracts are critical to the success of the PPP initiative: both for
infrastructure and for service contracts. There is a critical need for adequate contract
management knowledge and thus capacity building essential for government institutional
development so that PPP is delivered properly. Current PPP unit is in place and can lead on this.
Finances & • The provincial government will allocate budgets for each year
commodities • The programmes, projects and schemes premised on the goals and objectives of the Policy 2015,
covering all out efforts at reaching population replacement level by 2032 and advancing towards

28
 stabilization by 2045, will be adequately resourced and sustained in view of their critical
importance and linkage with provincial development endeavor
• Other sources of finances including the annual development program finances (ADP) , donors
and development partners; UN agency contribution and INGOs can also be tapped
• Soft loans from international financial institutions and tax exemption from government for the
commodities can also be tried to arrange needed resources.

Punjab
public-private Partnership • The Punjab public-private Partnership Act 1X of 2014 exists. There is a PPP cell within Planning &
Government of Punjab Development Department , Government of Punjab
• A public –private partnership for health sector projects thus far has taken the form of management
contracts with hospitals.
• FP projects can also be explored with assistance from the PPP department.

Objectives of PPP The PPP will aim to promote

• use of contraceptive to increase the CPR
• discourage abortions to prevent the birth of unplanned child

Service delivery and services • Area of collaboration will be the mother and child health and under this umbrella FP services can be
Integration provided by private sector providers. (This implies the linking of FP with MNCH)

Governance • Government can outsource the project to private parties and both parties are to abide by the terms
of the contract

Planning • Under the existing PPP in Punjab, there are 2 types of PPP projects, one is solicited PPP project and
other is un-solicited PPP project. Solicited project means that government agency will identify and
conceive the project, they can have any consulting firm involved in PPP transactions for them, and
develop a whole PPP project.
• Unsolicited projects are planned by private sector parties and submitted to the government for
acceptance

Implementation • There could be 3 models for implementation of FP projects under existing PPP:
• Evening service in PWD centers can be outsourced to private sector to provide FP services
• Mother and child health care centers of public sector hospitals can be outsourced to private parties
through a management contract and they can work for promotion and service delivery of FP
• ‘Built on upgrade transfer’ or ‘built on operating model’. Under this model private parties can build
model mother and child heath care hospitals with initial support from the government (grant of
land for construction of facility) under a contract regarding their future ownership and operations

Human Resource • Since government will outsource the facilities, human resource needed to run these facilities will
naturally will be the responsibility of private sector

Finances & commodities • The government will provide the facilities (in other words cost of infrastructure) or soft loans to
build MCH facilities to private sector and private sector will be responsible for their operating
expenses.

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Annex - 2 Global PPP Experiences
The literature has many examples of public-private partnerships playing a significant role in increasing
the use of contraception and reducing population growth rates. In many developing countries,
including South Korea, Thailand, Indonesia, and Morocco, governments encouraged PPPs by
introducing policies that enabled private providers to deliver FP services as well as supplies.
Providers played an important role in motivating potential users to make informed decisions about
achieving a small family size. NGOs’ outreach workers were used for interpersonal communications
with potential users to clear myths and misperceptions about contraceptive use. The successes
achieved by various public-private partnerships and the role of both partners in the partnerships are
summarized in Table 4.
Table 4: Global examples of public-private partnerships
Country Role of public sector Role of private sector Impact
South • Strong leadership • Private physicians trained • Increase in CPR from 18% in 1964 to
Korea endorsement and engaged over 80% in 2001
• Intensive outreach and • Service voucher program • Decline in TFR to below replacement
education effort for long-acting reversible level
methods (LARMs)
Thailand • Provision of pills and IUDs • Popularization of FP in • Increase in CPR from 14% in 1970 to
by midwives communities through 70% by 1993
Population and Community • Decrease in TFR from 6.3 in 1963 to
Development Association 1.7 by 2003
Indonesia • Promotion of small family • Pioneering of private • Increase in mCPR from 5% to 57%
norm provider networks • Decrease in TFR from 6 to 2.6
• Engagement of religious
leaders
Morocco Authorization of Direct-To- • Pharmacists trained • Increase in pill use from 16% to 21%
Consumer (DTC) marketing and • Lowering of oral • Increase in mCPR from 20% to 289%
advertising contraceptive prices by • Decline in TFR from 4% to 2.5%
manufacturers

Notably, among the examples listed above, Indonesia’s PPP is of special relevance to Pakistan. In
1995, a public and private sector team supported by PSI visited Indonesia on a study tour to learn
about the private provider network model there. This was then replicated by Greenstar Social
Marketing (GSM) in Pakistan as the “Sabz Sitara” franchise network which became the largest
private sector family planning/reproductive health network in the world. This franchise model has
not only been replicated in Pakistan but also in several other countries in Asia and Africa.
One of the lessons that can be learnt from PPP programs that have had a national impact is that
that they are built on a sound PPP framework which defines the policy, procedures, institutions, and
rules that together direct how the PPP will be implemented. The key levers of global PPP success
examples include high level of political and policy support; certainty of payment for the private sector;
and underpinning of the PPP program by a legal framework. In addition, in successful cases, the
government was the funder providing grant, capital, or asset support to the private sector, which was
engaged in provision of FP services on a contractual basis, and the role of regulator also remained
with the government while the role of coordination was assigned to an interface agency, such as an
NGO, SMO, or professional association.

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 The Paris Declaration on Aid Effectiveness, signed by over 100 developed and developing countries
in 2005,29 presents the following five important principles for PPPs, which we recommend should be
used as the driving force in Pakistan’s PPPs:
1. OWNERSHIP – PPPs are owned by the government, which identifies its own strategies, and
improves its institutions;
2. ALIGNMENT – All organizations bring their support in line with the government’s strategies and
use local systems;
3. HARMONIZATION – Organizations coordinate their actions, simplify procedures, and share
information to avoid duplication;
4. RESULTS – There is a focus on producing—and measuring—results; and
5. MUTUAL ACCOUNTABILITY – All parties are accountable for results.

Tanzania Policy: Public- Private Partnership

Since the mid-1990s, the Tanzanian government has followed a policy of public-private
partnerships. According to the Tanzanian Ministry of Health’s 2006 annual report, private service
providers now account for 40 percent of health care provision in Tanzania. The remaining 60
percent is covered by the state. In order to reach the ambitious targets of the Tanzanian health
programme, both parties cooperate with one another, share resources, and coordinate their
services.
The development of a service agreement between state and private health care providers has
been approved by the Ministry of Health and the authorities for regional administration and
community policy.
The Tanzania NGO Alliance Against Malaria (TANAM), a national level NGO consortium, used the
PPP approach to address malaria control. This PPP demonstrated that relationships between the
public and private sectors may begin from very humble and loose beginnings. However, with
perseverance from committed individuals, vision, and trust, the partnership relation may become
powerful advocates for meeting prescribed health agendas.
Source: TANAM (2008) Tanzania National Malaria Movement (TANAM) - First breath fresh air conference - November 18-20, 2008.
AMREF and European Union.

29https://www.oecd.org/development/effectiveness/parisdeclarationandaccraagendaforaction.htm

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Annex - 3 Glimpses from provincial consultative meetings for
developing PPP framework
Peshawar - November 16, 2018

Lahore - November 24, 2018

Quetta - December 12, 2018

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