1

CHAPTER 1
INTRODUCTION

India was rated as the tenth largest economy in the world in the new millennium. The
impressive economic growth in recent times in the country has not been accompanied by a
commensurate decline in poverty or improvement on social, particularly health indicators. In
India, women‘s health, particularly reproductive health has consistently been a cause for
concern and public debate. Multitude of factors ranging from intra-household and community
based social discriminatory practices, socioeconomic disparities and health system failures have
been recognised as contributing to women‘s health. Vulnerabilities of women are further
exacerbated among women who are illiterate, young, poor, belong to the Scheduled Caste (SC) or
the Scheduled Tribe (ST), or are residents of rural areas.

The public spending i.e. recurrent and capital expenditure on health at around 1.3 per
cent of the Gross Domestic Product (GDP) remains one of the lowest in the world. With more
than three fourth of the State funds spent on salaries rather than infrastructure and equipment,
it is no surprise that the health system is short of facilities, hospital beds, trained manpower,
equipment, supplies and adequate physical infrastructure. These infrastructural problems of
service delivery are compounded by centrally sponsored health programmes which are not in
harmony with the local needs (Kumar and Gupta 2012). As a result, despite the economic
environment, progressive policies and five year plans people continue to have unaddressed
reproductive health needs.

District Level Household and Facility Survey 3 (DLHS 3) conducted in 2007-08

brings to the fore some of the unaddressed health needs especially reproductive health needs
of women in the country (IIPS 2010). A subsequent coverage evaluation survey in 2010
(UNICEF 2010) reconfirms absence of significant improvement in meeting women‘s
reproductive health needs. The data implies that reproductive choices, decision-making and
high standards of sexual and reproductive health are far from reality for women in the
country. Studies show that as compared to men, women in the country are disadvantaged not
only because of their gendered vulnerabilities but also because they belong to a specific caste,
class or educational status (Chatterjee and Sheoran 2007). There is a higher incidence of
mortality and morbidity among women who are poor, less educated and socially
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disadvantaged. The disadvantaged have benefitted little from the economic prosperity
resulting from the economic reforms and globalization. Rather, empirical evidence points
towards increase in disparities and continued unmet needs amongst women. United Nations
(UN) agencies suggest that health system lacunae, socioeconomic disparities and
discriminatory social practices are responsible for this scenario and high maternal morbidity
and mortality (CRR 2008).

Government of India (GoI) has tried to address the situation. India is a signatory to the
Programme of Action of the International Conference on Population Development (ICPD) in
1994 which stated,

‘Reproductive rights embrace certain human rights that are already recognized in national
laws, international human rights documents and other consensus documents. These rights
rest on the recognition of the basic right of all couples and individuals to decide freely and
responsibly the number, spacing and timing of their children and to have the information
and means to do so, and the right to attain the highest standard of sexual and reproductive
health. It also includes the right to make decisions concerning reproduction free of
discrimination, coercion and violence as expressed in human rights documents‟ (UNFPA,
DIHR and UNHR 2014:13)

The Supreme Court of India has ruled that failure to provide timely medical care
amounts to violation of the right to life under Article 21(Kumar and Gupta 2012). Provision
of health facilities and requisite services is a constitutional obligation of the government and
entitlement of citizens of India. Indicators of women‘s health reflect the country‘s efforts to
support women‘s basic right to life, equality, reproductive health and autonomy. Yet, essential
reproductive health services are not available to the majority (70%) of women in India
through the public health system (IIPS 2007). At the systemic level the poor performance on
health indicators in India has been largely attributed to inadequacies in availability,
accessibility, acceptability and quality of health services, particularly in the public sector
health system (CRR 2008). To improve the performance of the public health sector,
successive Five-Year Plans since 1992 (Planning Commission 1992) have stressed on the
need for health sector reforms. Public Private Partnerships (PPPs), one such reform has a very
strong symbolic appeal as it envisages bringing together the two sectors to improve the health
of the poor and deprived sections of the population. At the core of this is the assertion that the
locally available and better managed private sector will facilitate accessibility, efficiency,
accountability and cost effective and good quality services (Venkat Raman and Bjorkman
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2009). There is a need to examine this theme of PPP as a way of making an impact
particularly on reproductive health of under-privileged women.

1.2 Reproductive Health Scenario in India

The Government of India needs national and district level data on facilities, service
use and perceptions of people about services for implementation of its health programmes.
The National Family Health Surveys (NFHS) and District Level Household and Facility
Surveys (DLHS) are conducted to fulfil this need. The data from these surveys illustrates the
prevailing reproductive health scenario, provides benchmark for assessing improvements
over time and is the mainstay of health related plans and programmes.

Indicators of reproductive health for the country have shown some improvement over
the years, but these are still far from the desirable and from the goals set under various
international agreements and national policies. For instance, in NFHS III in 2005-06 the
mean age at marriage for girls at 19.8 years was higher than 19.5 years at NFHS II conducted
in 1998-99. Yet, 47.4 per cent women in the age group 20-24 years were reportedly married
before the age of 18 years and 16 per cent of girls in the age group 15-19 years were either
pregnant or already mothers in 2005-06 at the time of the survey (IIPS 2007). Contraceptive
prevalence for modern methods increased by 1.5 percentage point to 47.1 per cent but the
unmet need for contraception remained as high as 21.3 per cent. A little less than half
(48.4%) of the women in the age group 20-24 years reported birth order of two or more.
Adolescent girls (15-19 years of age) and young women (20-24 years of age) were estimated
to contribute to 47 per cent of the total fertility and 45 per cent of total maternal mortality
(IIPS, 2010). Despite more than two and a half decades of initiatives to control anaemia
amongst women, 56.2 per cent of women in the reproductive age group (15-49 years) were
still anaemic. The percentage of anaemia was higher amongst pregnant (57.9%) and lactating
women increasing their vulnerability to complications and death (IIPS 2007). Performance on
select reproductive health indicators is presented (see Table 1.1).
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Table 1.1: Select Reproductive Health Indicators

Indicator India
Marriage age
Mean age at marriage for girls@ 19.8 years
Women aged 20-24 years married by age 18 years* 47.4%
Fertility and contraception
Women 15-19 years who are pregnant or mothers* 16.0%
20-24 year old women with >=2 children@ 48.4%
Couple Protection Rate@ 47.1%
Unmet need@ 21.3%
Maternal care
3 Antenatal check-ups@ 49.8%
Institutional delivery@ 47.0%
Postnatal check-up in 1st 2 weeks@ 49.7%
Nutritional status
Ever married women who are anaemic* 56.2%
Women with Body Mass Index below normal* 33.0%
Vital rates
Total Fertility Rate* 2.7 children /woman
Infant Mortality Rate# 42 per 1000 live births
Maternal Mortality Rate$ 178 per 100,000 live births
Sources: *: NFHS III 2007-08. IIPS (2007); @: DLHS III 2008-09. IIPS (2010);
#: SRS 2012. RGI (2013); $: SRS 2010-12. RGI (2013)

Since the launch of the Reproductive and Child Health (RCH) programmatic
interventions in 1997, vital rates such as Total Fertility Rate (TFR), Infant Mortality Rate
(IMR) and Maternal Mortality Rate (MMR) showed a decline. The TFR declined from 2.8 to
2.7 children per woman, the IMR from 67.6 to 57 per 1000 live births and MMR from 212 to
178 per 100,000 live births (see Table 1.1). Once again this decline was nowhere close to the
targets set for achievement. Moreover, though the Sample Registration System (SRS)
reported a decline in the Maternal Mortality Rate, more than one third of these deaths were
due to direct causes such as haemorrhage either in pregnancy (Ante-partum) or after delivery
(Post-partum), puerperal sepsis (11%), unsafe abortion (8%), Obstructed labour (5%),
hypertensive disorders of pregnancy including Eclampsia (5%) and indirect causes such as
Anaemia (34%) (RGI and CGHR 2006). Majority of these deaths are preventable with timely
and appropriate antenatal care and emergency obstetric services (RGI 2011). The logical
question pertaining to the Reproductive and Child Health (RCH) programme is whether
women received the care they needed and deserved with the launch of the programme.

The District Level Household and Facility Survey 3 (DLHS 3) of 2007-08 provided
data on the service coverage amongst women. It showed that only half (49.8%) of the
interviewed women during their last pregnancy had received the recommended three
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antenatal care visits, 47 per cent had institutional births, and 49.7 per cent received postnatal
care within 2 weeks of delivery (IIPS 2010). The UNICEF Coverage Evaluation Survey
conducted a year later in 2009 showed that there were some improvements in safe delivery
and postnatal care. Three fourths of the women had safe delivery (72.9% institutional and
3.3% at home conducted by trained birth attendant) and postnatal care within 10 days of birth
was reported by 60 per cent (UNICEF 2010). The survey also raised questions about the poor
quality of care. While 90.4 per cent of pregnant women had received some antenatal care and
81 per cent had received Iron Folic Acid (IFA), less than 36 per cent had received the
recommended dosage, 31 per cent had consumed it and only 26.5 per cent had received the
recommended ―Full‖ antenatal care (Urban:36.1%, Rural: 22.8%).

The low coverage and poor quality of services was notable given the fact that
maternal care services have been the consistent focus of Government of India‘s various
programmes. Despite entitlement for free or subsidised services, barely half of the women in
the UNICEF survey had sought routine maternal care from government centres or public
hospitals. Of the 72 per cent of women in the survey who reported complications during
pregnancy such as giddiness (37.6%), oedema over face and feet (29.4%), vomiting (28.1%),
fatigue (25.4%), visual problems (12.5%) and loss of foetal movements (10.8%), significantly
more sought treatment at private facilities (54%) rather than government or public facilities (13%).
Similar preference for private was noted for other reproductive health needs also. In a study in
rural Tamil Nadu, one third of the interviewed women reported signs and symptoms of
Reproductive Tract Infections (RTIs) and Sexually Transmitted Infections (STIs) in the past
12 months. Only half of the women with signs and symptoms sought treatment and two-
thirds of those who sought treatment preferred private health care (Mani et al. 2013).

The reasons for these preferences in health seeking were clear. In the UNICEF survey,
women reported travelling on an average 7 km to seek care. Only 37.4 per cent of the women
had used either an ambulance or a jeep or car to reach the health facility for delivery. Women
spent Rs. 100 or more in rural areas, something which they could ill afford as 54 per cent of these
women in rural areas belonged to the two lower most quintiles of wealth index. While government
or public services were found to be not convenient or free, private were perceived to be too costly.
In a study by United States Agency for International Development (USAID), most women
reported incurring debt for institutional care, particularly so in private institutions (IIPH
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2010). It was therefore not unusual that a fifth of those who delivered at home claimed that
they received ‗better care at home‘ and preferred it and another 17.9 per cent mentioned that
it ‗costs too much‘ to access an institution for delivery (UNICEF 2010). The UNICEF survey
also revealed that about 35.6 per cent women in rural and about 25.9 per cent women in
urban areas in India, which comprised about one third of those who had complications during
pregnancy in the country, did not seek treatment.

This data from large national level surveys while indicating reproductive health needs
of women also revealed that public health system was neither reaching all women nor was it a
place of choice for them. What were government‘s policy pronouncements, the programme
strategies and efforts at field to address the address this complex situation?

1.3 Interventions in Reproductive and Child Health

A range of interventions have been undertaken by the government to address

women‘s reproductive health needs. This section focuses on the enabling policy environment,
the realisation of policy intent, the budgetary provisions for programmatic strategies, the
strengths and weaknesses of both public and private health sectors and outlines the context
for health sector reforms such as PPPs.

Policy environment: India is a signatory to the Alma Ata declaration of 1978 which
emphasized the need for primary health care and proposed ―Health for All by year 2000‖. Till
1983, when the first National Health Policy (NHP) was formulated, the recommendations of
Bhore Committee of 1946 and the Alma Ata declaration formed the guiding principle for
India‘s health service delivery. Rapid population growth was the reigning concern at that time
and therefore priority was given to targeted family planning programme.

The 1983 National Health Policy (NHP 1983) was formulated on the lines of the
intent of Alma Ata declaration. Its objective was to provide comprehensive primary health
care for all the citizens of the country. To achieve this objective capacity building of health
personnel and co-option of different systems of medicine in the health care delivery system
were identified as priority areas (MoHFW 1983).
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Till the early 1990s the NHP 1983 guided the health programmes and service delivery
in the country. In response to the visible demographic transition, the Child Survival and Safe
Motherhood (CSSM) programme was launched in 1991 to improve access to maternal and
child health services and to ultimately reduce fertility and mortality. In 1994, the
International Conference on Population and Development (ICPD) was held in Cairo. At the
conference 179 of the participating countries signed the Programme of Action (PoA) that
urged for a comprehensive sexual and reproductive health approach for population and
sustainable development. India too was a signatory to the PoA at the ICPD. In response to its
commitment, the Government of India launched a Reproductive and Child Health programme
(RCH) in 1997. The aim of this programme was to reduce infant, child and maternal
mortality rates. The strategies listed included participatory planning, strengthening of
institutions, improvement in scope, quality, coverage and effectiveness of existing family
welfare services and emphasis on unreached and under-served areas. In this new approach
districts were the units of design. The programme was not only expected to provide quality
reproductive health services but also facilitate a shift from the traditional target-based health
services to client-centred, demand-driven reproductive health services.

In the year 2000, a Millennium Summit was organised in New York. At the summit
all the 189 participating countries expressed their commitment to the right to development,
gender equality, eradication of poverty and improvement in health. These were formally
articulated in the United Nations Millennium Declaration and goals were set for signatory
countries. Three of the eight Millennium Development Goals (MDGs) set at the summit
directly pertained to reproductive health (Goal 4: Reduce child mortality, Goal 5: Improve
maternal health and Goal 6: Combat HIV/AIDS, Malaria and TB). The MDGs were to be
achieved by 2015. Government of India adopted the Millennium Development Goals
(MDGs) framework for development. By then it was also evident that the goals specified for
vital rates and service coverage in the NHP 1983 had not been achieved. A comparison of
actuals with targets on select reproductive health indicators is presented (see Table1.2). It was
becoming clear that with limited resources and existing capacity of the public health system it
was not possible to achieve these goals.
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Table 1.2: Targets and Achievements

Indicator Goal for 2000* Achieved by 2000@

Vital Rates
Growth Rate 1.2% 1.93%
Net Reproductive Rate 1 1.42
Crude Birth Rate (per 1000 population) 21 26.1
Crude Death Rate (per 1000 mid-year population) 9 8.7
Maternal Mortality Rate (per 1000 live births) 2 4
Infant Mortality Rate (per 1000 live births) 60 70
Post-Neonatal Mortality Rate (per 1000 live births) 30-35 46
Life expectancy (Male) (years) 64 62.4
Life expectancy (Female) (years) 64 63.4
Service Coverage and Performance
Low Birth Weight 10% 26%
Contraceptive Prevalence Rate 60% 46%
Average Family Size 2.3 3.1
Antenatal Care Coverage 100% 67%
Tetanus Toxoid Coverage 100% 83%
Full immunisation 85% 56%
Sources: *: MoHFW (1983); @: Majra (2003)

At the turn of the century in 2000, Government of India launched the National
Population Policy (NPP), 2000 (MoHFW 2000). The policy re-iterated the Government‘s
commitment to economic and social development and environmental protection through
stabilised population growth. The policy explicitly stated the need for advancement of
reproductive health of the country‘s population by providing comprehensive reproductive
health services. It listed a set of socio-demographic goals to be achieved by 2010.
Acknowledging the government health department‘s inability to meet the reproductive needs
on its own, the policy proposed inter-sectoral co-operation and collaboration with the
voluntary, non-government and the private sector. Themes in focus in NPP 2000 were child
health and survival, need of family welfare, underserved and unreached population and
involvement of men. Strategies outlined to address these themes included decentralised
planning, empowerment of women, mainstreaming of other systems of medicine and
involvement of the private sector.

NPP 2000 sought private sector involvement for specific aspects of service delivery.
It sought social marketing for affordable products and services and floated the idea of soft
loans to locals to operate ambulances and network of private providers to provide free
services. Keeping in mind the strengths and expertise of various components of the private
sector, it suggested advocacy, Information Education and Communication (IEC) and
counselling by the Non-government Organisation (NGO) sector. In addition participation of
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the corporate sector was suggested to strengthen the management of the government
reproductive health services through improvement in the Management Information System
(MIS) pertaining to the health sector. The NPP 2000 however cautioned about the challenges
associated with contract terms, accreditation of facilities, regulation of services, referral
mechanisms and clarity of roles and responsibilities in the collaboration with private sector
(MoHFW 2000).

In 2002, Government of India also launched a National Health Policy (NHP 2002)
(MoHFW 2002). The larger intent of this initiative was to give impetus to achievement of the
Millennium Development Goals and to achieve good health for its people with the available
financial resources and public health administrative capacity in the country. The NHP 2002
prompted synchronised implementation with the NPP 2000 to improve health standard of the
country. It envisaged supply of essential drugs, a decentralised health system, convergence of
all health programmes under one administration (autonomous body) and community
monitoring and accountability of the public health system. The policy highlighted the need
for more resources, involvement of private sector, insurance for the poor, user charges for
those who could afford to pay and advocated increase in government outlay on health. In
view of previous experiences with the private sector, the policy also clarified that the
involvement of private should be sought mainly in urban primary and tertiary care and to a
limited extent in secondary care. For non-profit private sector it sought collaboration in
running of national programmes and public health outlets and in motivating people for
seeking care. The NHP 2002 was also perhaps the first categorical recognition of the
importance of standards of care. It mentioned the need for regulation of quality of care and
talked about legislation for infrastructure and quality standards, guidelines for clinical care
and accreditation of private facilities.

In continuation of series of these corrective actions, in 2005, the Government of India

launched the National Rural Health Mission (NRHM) to provide accessible, affordable and
quality health care to the rural population. The stated purpose was to put in place a
community owned functional model with inter-sectoral convergence and decentralised health
service delivery. The strategic aspects of NRHM included strengthening of state health
infrastructure, innovations in human resource management, decentralised management of
health, capacity building at all levels, flexible financing, communitisation of facilities and
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community accountability and monitoring against Indian Public Health Standards (IPHS).
The NRHM added a workforce of about 178,000 health workers at health facility and
900,000 Accredited Social Health Activists (ASHAs) at the community level and deployed
about 18,000 ambulances for emergency transport in its bid to strengthen health
infrastructure. In addition, it provided for cash transfers to about one crore pregnant women
annually to enhance use of services (MoHFW 2014).

How effective were these policies and programme measures in delivering on their
intent? The assessment of NRHM implementation reflected that use of reproductive health
services had improved. However, the improvement in the reproductive health indicators
varied across states and within states across districts. An analysis of situation using the
Reproductive Health Index1 (RHI) developed from the data of NFHS and DLHS III, for 29
states / Union territories (Parchure et al. 2011), showed that there were improvements on
several component indicators in the RHI. The Total Fertility Rate (TFR), Infant Mortality
Rate (IMR) and Birth Order (BO) of 3 or more showed a decline. There was also
improvement in other components such as institutional delivery and safe delivery and
components pertaining to education and literacy of women. However, of the ten largest states,
accounting for a significant portion of the country‘s population, only six had an RHI betters
than the average RHI for the country, and only four of these states were ranked within the
first ten ranks on RHI (see Table 1.3).

Table 1.3: Performance of Select States on Reproductive Health Index

State Reproductive Health Index RHI Rank

INDIA 41.0 Not applicable
Uttar Pradesh 20.2 29
Maharashtra 55.7 9
Bihar 20.7 28
West Bengal 54.1 11
Madhya Pradesh 30.9 24
Tamil Nadu 68.7 3
Rajasthan 31.9 23
Karnataka 56.1 8
Gujarat 45.7 16
Andhra Pradesh 57.9 7
Source: Parchure et al. (2011)

1
Reproductive Health Index: Reproductive Health Index or RHI has been calculated based on 5 variables: Total
Fertility Rate, Infant Mortality Rate, Birth Order, Delivery Care and Female educational attainment with each
being given equal weightage.
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Assessment of NRHM also showed that training, skill building and deployment of
human resources, building capacity of institutions launched under NRHM, streamlining
procurement and logistics, web based reporting and efficient utilisation of existing resources
required further strengthening.

By 2013, the increasing evidence of poor health and service availability in urban
areas, especially urban slums made Government of India to launch the National Health
Mission (NHM) with National Urban Health Mission (NUHM) and NRHM as its two sub-
missions. The aim of NHM is more comprehensive and includes reduction of total fertility
rate, anaemia amongst women, maternal and infant mortality, mortality and morbidity from
injuries and diseases and out-of-pocket expenditure of households on health care in both rural
and urban areas. NHM offers flexibility to the states to plan and implement state specific
action plans that reflect aspirations at district level.

The intent of NHM was reflected in the XIIth Five Year Plan which was formulated
for the period 2012 to 2017. The objective of the plan was to ensure efficient and effective
utilisation of country‘s resources to achieve universal health coverage. The strategies to
achieve that encompassed enhanced access to a range of services and essential medicines,
either free or at affordable price. The strategies proposed in the plan document include
increase in public sector expenditure to 2.5 per cent of GDP, efficient use of available
resources and expansion and strengthening of public health service delivery. In a bid to
address quality issues within public and private sector the plan articulates the importance of
trained and skilled human resources, standard treatment guidelines, stringent monitoring and
effective regulation. It foresees role of private sector in ensuring continuum of
comprehensive health care in areas where public health system is unable to provide it on its
own. The High Level Expert group (HLEG) appointed for providing inputs on design of a
comprehensive strategy for health acknowledged the need for private collaboration. It
emphasised the need to move away from hitherto practiced ―ad hoc‖ private sector
involvement and proposed utilisation of private resources for strengthening tertiary care
(Planning Commission 2013).

The persistent under-performance of the public health system despite availability of

the latest effective and technical interventions and knowledge about them led the Government
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of India to draft a National Health Policy in 2015 (MoHFW 2014). The NHP 2015 recognises
the need to respond to the emergence of a health care industry growing at 15% Compound
Annual Growth Rate (CAGR). The policy focuses on addressing the increasing health care
costs and the availability of resources within the government system.

Thus the policies and plans in the recent past had started putting more thought into
addressing the issue of insufficient resources with the government, the increasing health care
costs and the consequences of both. Did this get reflected in budgetary provisions for
programmes and intended strategies?

Health sector expenditure: The allocation of funds for health as a percentage of total
plan outlay of Government of India has always been low. The allocation declined from 3.3
per cent to 1.7 per cent by the VIIIth plan, and since then it has increased to 3.15 per cent in
the XIth plan. The NHP 2002 had recommended doubling of the annual budget of department
of family welfare so as to meet the infrastructural needs of the public sector, thereby implying
a significant increase in allocation for health in the plan outlay. However the allocation for
health even in the XIIth five year plan is short of the requirement and inadequate to undo the
ill effects of consistent low budgetary allocation to the health sector.

Public spending on health has been consistently inadequate in the country, much
lower than private expenditure on health. In 2012, the total expenditure on health care in
India was estimated at 4.1 per cent of the GDP. The public expenditure accounted for 27 per
cent of the total expenditure on health. Though health expenditure as a percentage of GDP is
higher in India than other neighbouring Asian countries, public spending as percentage of
total health expenditure is significantly lower than these countries barring Pakistan. Less than
one third of health expenditure is by public and the rest by private sources.

Health is a state subject in India and the responsibility of providing health care largely
rests with the states. The outlay on health depends on the financial health of the state as well
as the budgetary allocation from the centre. Till 2005, funding to individual states was on
normative basis. Post NRHM, funding to states is driven by approved Project Implementation
Plans (PIPs) of the states. In general, the declining health budgets are known to impact the
central allocation to state health budgets. The low budgetary allocations for health come in
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the way of providing good quality primary, secondary and tertiary health care to its citizen.
The situation is often worsened by the five yearly release of funds, the limited flexibility for
spending given the strictly defined budget heads and the inequitable distribution with more
funds being earmarked for urban health care. The need for expansion of health services is not
adequately covered by the available budgets. More than two thirds of these budgets go into
payment of salaries and other recurring expenses rather than for up-gradation and expansion
of infrastructure. Inefficient utilisation of even the limited budget for creation of
infrastructure worsens the service delivery mechanisms of the states even further. Absence of
facilities, equipment and supplies at public facilities means that people often have to pay for
getting services or medicines or opt for private care. Out-of pocket (OOP) costs account for
close to 60 per cent of health expenditure (WHO 2012).

The NHP 2002 recommended increase in contribution by the central government to

meet the resource requirement to provide adequate health services to population of India. It
proposed an increase in sectoral outlays with allocation of 55 per cent of public health
investment for primary, 35 per cent for secondary and 10 per cent for tertiary health care. The
policy also suggested that investment in primary health care be used to strengthen the health
care infrastructure (MoHFW 2002). In 2013 the High Level Expert Group set up by the
Planning Commission for the XIIth plan recommended that the public expenditure on health
should be raised from the current level of 1.2 per cent of GDP to 2.5 per cent by the end of
the plan and to 3 per cent by the end of 2022. Going beyond the NHP 2002, the HLEG
recommended that primary health care should account for 70 per cent of the health care
expenditure of the government. The HLEG also proposed that to raise resources for health
sector, health should be included in the infrastructure sector so as to be eligible for viability
gap funding. In addition, the HLEG recommended that public funded facilities should be
allowed to receive funds under Corporate Social Responsibility (CSR) from the corporate
sector, with the caveat that these funds would not substitute the funds being received from the
government under existing programmes. Attempts are being made to augment the diversity of
sources for funding - user fees, donations and involvement of the private sector – to ensure
that the quality of health services improves over time and is not starved of funds.

Thus the policy prescriptions and plan strategies reflect the recognition of the
burgeoning need for resources to find solutions to problems associated with health. However,
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till the resources are substantially augmented, the ever increasing revenue expenditure and
the consequent limited availability of funds for capital expenditure will continue to have
adverse effect on public health system and ultimately on health care for the poor. The budget
constraints do not permit realization of the strength of government or public health system to
deliver health services. Such a situation has long term negative implications for the health of
the less privileged which in turn has negative implications for the social and economic
development of the nation. The question that arises is whether involvement of the private
sector is the answer to enhancing resources and the quality of delivery of health services?

Strength and weakness of public and private sector: Under the VIIth schedule of the
Constitution of India it is the state‘s responsibility to provide health care to its people.
Currently the health needs of people are met through a network of municipal corporation,
government or public and private (formal and informal) health service providers. About 30
per cent of the country‘s 1.21 billion population is below the poverty line (Planning
Commission 2014). Meeting the health needs of this stratum of the society is a priority for the
government.

The public sector aims at providing services to a large section of the population,
mainly to the vulnerable and un-reached population. In the rural areas the public health
system is organised in a three tier structure. It provides preventive, promotive, curative and
rehabilitative care through a mammoth network of facilities. As of 2014 the country‘s rural
primary and secondary public health network consisted of 152,326 subcentres, 25,020
Primary Health Centres (PHCs) and 5363 Community Health Centres (CHCs) (DoHFW
2014).

But the public health system has several deficiencies. The inadequacy of public
facilities is evident from the following statistics: about one fourth of the subcentres, 15 per
cent of PHCs and five per cent of the CHCs do not have their own building and requisite
infrastructure. There is serious shortfall in human resources, particularly at the secondary care
level; staff vacancies range from 2 per cent of the required strength for Auxiliary Nurse
Midwives (ANMs), 12 per cent for doctors at the PHCs, 81 per cent for specialists at the
CHCs and 21 per cent for nursing staff at the PHCs and CHCs. More than one third of the
CHCs (34.8%) even today lack functional operation theatre and a majority (81.3%) of them
 15

do not have facilities and skilled manpower to conduct Caesarean operations (MoHFW
2014). Inadequate financial resources and absence of autonomy affect tertiary care hospitals
in public sector (Bhat 2000). Lack of adequate and functional facilities, shortage of
adequately trained manpower and availability of medicines and other medical supplies
severely hamper effective delivery of health services through public facilities.

Accessibility of public sector health services is another problem. Access to public

facilities is affected by location of the facilities, availability of staff and working hours of the
facilities. About 28.6 per cent of subcentres and 28.8 PHCs are located farther than the
recommended distance2 from the villages under their jurisdiction. Only 52.7 per cent of PHCs
work round the clock. About 43 per cent of the ANMS do not stay at their headquarters
(MoHFW 2010). A survey of public facilities revealed 40 per cent absenteeism among the
primary health service providers (Choudhury et al. 2006). More than three fourths (75.6%) of
PHCs do not have a Lady Medical officer (LMO), the preferred service provider for
reproductive health issues amongst rural women (IIPS 2010). The systemic deficiencies are
reflected in the perception of poor quality of care at public health facilities and in their low
use for health problems. Data shows that public sector accounts for less than one fourth of
inpatients and about 40 per cent of outpatients in the country (Venkat Raman and Bjorkman
2009)

The private sector on the other hand is perceived to provide focussed cost effective
and good quality services (The World Bank 2003). The services are also seen to be more
attentive to the needs of the patients and have greater potential for innovations.
Accountability of providers of health services in the private sector is perceived to be greater
as they have greater authority compared to the providers in the public sector (Mitchell 2008).
The Private sector however is not without its own shortcomings. The qualifications of private
providers vary significantly, from highly qualified allopathic specialists, to providers from
Indian System of Medicine (ISM) to traditional healers and other informal providers. The
sector is completely unregulated and does not conform to the standard guidelines for
managing health related problems (Jesani and Nandraj 1994). The private providers are

2
A health facility is expected to be within 30 minutes of walking distance (MoHFW 2014)
 16

largely motivated by commercial interests and therefore their facilities are located mostly in
thickly populated urban areas. Their services too are aimed at people who can pay. Seeking
care in the private sector is invariably associated with high costs. It is estimated that crores
are spent in a year by households for private care and most of it is during health distress
situations. It is believed that about a tenth of the population is required to sell assets to meet
health related expenses. As a result of these expenses, it is estimated that about three per cent
of population is pushed into penury every year (MoHFW 2005).

Thus, both the public and the private sectors have their strengths and weaknesses. The
supportive policy environment, the recognition of insufficient financial and human resources
and of the inability of the public health system to meet the unmet need of people has
prompted the government to go for health sector reforms. Greater formal involvement of
private sector through PPPs is one such reform. These are attempts to leverage the strengths
of both the sectors to overcome the shortcomings of both the sectors and meet the unmet
health needs of people. What has been the nature of design of such PPPs to overcome the
shortcomings of both the sectors to meet the health needs of people? How have these PPPs
performed thus far?

1.4 Public Private Partnership (PPP) in Health Sector

In India, PPP is seen as the perfect solution to the infrastructural and functional
deficiencies of the public health system. The synergy between the strengths of the public and
the private sector is expected to be harnessed through PPPs to achieve good health for people.

Government partnership with the private sector is not new to India. It has existed in
national programmes since the first five year plan (1951-56). Till the advent of health sector
reforms and the PPPs in their present form, however, partnerships with the private sector
were limited and largely informal or ad hoc. Increasing importance of efficiency in service
delivery required a more formal, equitable relationship between the two partners to deliver
comprehensive services (Baru and Nundy 2008). PPP was seen as one way of addressing the
severe budgetary constraints afflicting the government plans, programmes and schemes. The
role of the private sector was therefore expanded to include resource generation and
infrastructure support for delivery and monitoring of health services. The ―for profit‖ private
 17

sector started playing a more active role in the Reproductive and Child Health (RCH)
programme by the late 1990s. The first phase of the RCH programme focussed on service
delivery constraints and the second phase on reaching the unreached through demand side
financing and innovative service delivery mechanisms in partnership with the private sector
(Bhat et al. 2007).

A number of PPPs with varying degree of public and private partner involvement
have been and continue to be implemented in the country. Social marketing of contraceptives
and Oral Rehydration Solution (ORS), contracting out of health facilities and contracting in
of select services at health facilities, voucher schemes for select services and joint ventures
for tertiary care hospitals are some of the examples of PPPs prevalent in the health sector in
the country. Most of these PPPs deal with reproductive health services and a few with the
national programmes. Several states have started using PPPs to deliver health services to their
population.

Gujarat has been at the forefront in implementing health sector reforms. Of the
reforms, the PPPs have a very long history in the state with the much celebrated example of
a primary health centre being managed by Society for Education, Welfare and Action Rural
(SEWA Rural) in the 1980s (UNNATI and Vadodara Medical College 1999). Chiranjeevi
Yojana, a more recent PPP designed, developed, piloted and scaled up successfully in the
state (Mavalankar et al. 2009), is on the threshold of being implemented in other states in the
country. The state ranks 9th among the 20 major States in the country on Human
Development Index though it is one of the economically advanced states (Drèze and Khera
2012). Improvement of Human Development Index (HDI) is a stated priority of the State
government and therefore the state has announced certain health sector reforms with larger
scope for PPPs (Gujarat Social Infrastructure Development Society 2015).

PPPs including those launched in Gujarat are seen by the State government to have
succeeded to a certain extent in providing an efficient, flexible, equitable cost effective and
viable alternative for government or public health service delivery, particularly for
reproductive health. But there are also concerns about the quality of care provided in view of
the range of providers with varying qualifications and skills, absence of standard health care
guidelines, regulations and monitoring. There are apprehensions that the private sector may
 18

serve only those who can pay or may make profits through supply of more health care than
what is needed.

The performance of these PPPs tends to get measured largely in terms of

infrastructural indicators such as staff deployment, functional centres and to a limited extent
in terms of service coverage. However there is lack of concrete evidence on health outcomes
of PPPs and whether they indeed serve the larger interests of women. There is therefore a
need to revisit the concept of PPP and study the extant PPPs in detail to infer whether the
synergy between the public and the private partners has indeed been achieved as per
expectations to improve health care in the country.

1.5 Objective of the Study

The purpose of the study is to examine the very theme of PPP as a way of addressing
the reproductive health of women. The study seeks to investigate whether the PPPs indeed
measure up to the inherent expectation that they would significantly improve reproductive
health services. In view of a long history of using PPPs in its health sector, the study is
located in Gujarat.

The study proposes to

1. examine the effect of select models of PPP on availability, use, cost and
quality of health service delivery to women as perceived by them, and
2. investigate the attributes of the three different models of PPPs that account for
this effect on availability, women‘s preference, access, use and satisfaction
related to reproductive health services.

1.6 Chapters

The thesis is presented through eight chapters.

Chapter 2: Chapter 2 provides a comprehensive literature review on PPPs to set the

stage for the empirical analysis carried out on the effectiveness of such partnerships in the
 19

Indian context. It describes the concept and the theoretical perspective of PPP in terms of the
macro and micro level factors and economic theories relevant to provision of services. Based
on these it generates a theoretical framework for PPPs in health sector that graphically
represents various political, economic, institutional and socio-cultural influences on PPP
models for reproductive health and in turn their influence on women‘s reproductive health. It
then gives historical perspective for genesis of PPPs in India followed by classifications of
PPPs and different PPP models in the health sector in existence globally and in India,
particularly in the State of Gujarat. The next section illustrates the empirical evidence of
operationalization of PPP models, particularly for women‘s reproductive health in India. It
ends with a debate on the concept, vocabulary, power relations and other relevant concerns
against the backdrop of the overall theoretical, historical and empirical context.

Chapter 3: Chapter 3 explains the study methodology. The Chapter starts by

specifying the research objectives and research questions. It then illustrates the conceptual
framework that guided the analysis. It elaborates on the operational definitions of terms used
in the study and the study design. It then goes on to describe the sample of PPPs to be studied
and the sources of information for studying these PPPs followed by the data collection
techniques planned and the tools developed for used in the field. It provides details of the
process of data collection in the field and the ethical considerations that were kept in mind
while collecting data. The data entry package and process followed are included in the
chapter followed by description about the various variables and the data analysis process
followed.

Chapter 4: Chapter 4 describes status of women‘s reproductive health over time in

India as well as in Gujarat, particularly in districts of select PPPs. While the country level
data is compared to other countries in the sub-continent, the State level data is compared to
the status of women‘s reproductive health in the country, in neighbouring Maharashtra and in
Kerala. The data is mainly from the international, national and state sources and surveys,
government MIS and studies conducted in the state. The chapter also includes description of
the existing government health service delivery system and its performance in Gujarat and
the performance of chosen PPP models on select women‘s reproductive health indicators.
 20

Chapter 5: This chapter includes description of three select PPP models in the context
of Government of Gujarat‘s conceptual framework and guidelines for PPPs in health sector.
The chapter elaborates on these PPP‘s location, physical infrastructure and the services they
offer. It then provides key informants perspective in general on PPPs in health sector and in
particular on three select PPPs. These perspectives refer to rationale for PPP in health sector,
the process of partnership, motivation of various partners, their roles and responsibilities,
partnership associated risks, outcomes and the sustainability.

Chapter 6: Chapter 5 describe primary findings of the study in terms of women‘s

perspectives related to reproductive health service delivery under select models of PPPs. The
findings are described in terms of socio-demographic and obstetric profile of women service
users, women‘s access to and use of these services in 12 months prior to the study, their
preferences, experiences and satisfaction with available services. The chapter then looks at
the perspectives of under-privileged women. The chapter also explains the results of
regression analysis conducted to relate women‘s preferences and satisfaction with their socio-
economic profile and attributes of select PPPs.

Chapter 7: Chapter 7 explores the theoretical framework for analysing contractual

relations for select PPP models. Subsequently the process of contractual arrangement in
select PPPs is analysed in the context of the seven steps specified by The World Bank for
drawing a contract. This is followed by a review of contentious aspects of the PPPs.

Chapter 8: The chapter summarises the unaddressed reproductive health needs of

women, government‘s attempts to address these and the health system reforms. In brief it
offers the theoretical context for PPPs through review of literature and underlines the
difficulties of designing a generic PPP model in health sector. It provides the rationale for a
study on PPPs in Gujarat, talks about the purpose and methodology of the study and
highlights how the study differs from other studies on PPPs. The chapter then sets the
background by describing the existing reproductive health scenario and PPPs in the State of
Gujarat. It moves on to look at select PPP models in terms of their level of operations,
motivation and roles and responsibilities of partners, funding, functioning and performance
and sums up women‘s preferences, access, experiences and satisfaction with these PPPs. This
is followed by institutional analysis of the PPP contracts to explore the micro aspects of these
 21

PPPs as modes of service delivery. The chapter provides conclusions about situation of PPPs
in the context of existing health policy environment, the type of contractual arrangements
needed and the performance and sustainability of PPPs. It ends by acknowledging limitations
of the study.