The journey of public-private partnership (PPP) in Bangladesh began officially in 2010 through the formulation of the PPP policy guidelines, which was followed by the Public-Private Partnership Act, 2015. Subsequently, this policy framework, led by favourable political leadership, oversaw an upsurge in PPP projects, particularly in energy and infrastructure.

However, when it comes to healthcare, the same has not happened. So far, only eight health projects have been conceived under PPP, and only two have reached operational stages. While PPP can be an effective tool to plug the gaps in healthcare infrastructure, as examples from different countries demonstrate, PPP projects can be tricky because success depends on a holistic policy framework that can address all aspects of healthcare. Different countries, including those from low to middle-income groups, have used PPP in healthcare, and their experiences can give us insight to how it can be utilised in Bangladesh as well.

Take, for example, the Lesotho national referral hospital, where a Public Private Integrated Partnership (PPIP) was established for the first time in sub-Saharan Africa, or in a lower income country. In 2011, a private consortium of hospital operators and partners was contracted to design, build and construct a 425-bed hospital and attached gateway clinics, and then provide all clinical and non-clinical services for 18 years. Of the USD 160 million budget, approximately 40 percent came from the government, a lion's share from development groups, and a small equity portion from private partners. But, with this facility, the government greatly expanded the scope, quality and volume of healthcare services in target areas.

Peru is a more recent entrant into healthcare PPP, but is the first country in South America to include primary care within the scope of a PPP. Two projects involved the building and operation of new hospitals in Lima, the capital of Peru, each with corresponding primary and urgent care centres. A third project was commissioned to renovate an abandoned building into an ambulatory care center. All three projects follow the DBOD (Design, Build, Operate and Deriver) scheme.

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Public-private partnerships also had positive impacts in Brazil, where the first PPP in health dramatically improved emergency hospital services for one million people in one of the most underserved districts of Salvador. The hospital was a new 298-bed facility opened in 2010. A consortium of local and foreign companies specialising in facilities management was selected to equip, maintain and operate the hospital services for 10 years, but the responsibility of delivering healthcare to the patients remains with the government.

Finally, India as a PPP case study demands additional attention, as its healthcare landscape most closely resembles that of our own. Some of the different PPP models and project types tried in India include offering land at subsidised prices for setting-up hospitals, where a part of hospital capacity is reserved for low-income patients; private parties taking over management of primary health care centres (PHCs) as well as rural hospitals; and outsourcing non-clinical services of public hospitals such as, dietary needs, laundry, etc. Specialised departments, such as diagnostics, gastroenterology, etc have also been outsourced in certain areas, as well as social marketing of contraceptives, which were outsourced to professional social marketing NGOs.

PPP in healthcare can be of different models – with DBOD and DBOT (Design, Build, Operate and Transfer) being the preferred ones in acute care/hospital projects. Other models also abound, from concessions in the form of subsidised land for hospitals to outsourcing of non-critical hospital services, as well as specialised treatment and testing to private partners.

When designing PPP projects, governments must consider the enhanced socio-economic benefits for target constituents as part of its success criteria and not focus on financial return alone. Private partners must be able to help the public sector in bringing health services to infrastructure-poor localities at affordable prices through expertise in healthcare management and/or access to capital.

There are a number of ways that we can engage in more public-private partnerships in healthcare. One is to set up a separate and dedicated government body that deals with healthcare PPP projects only, and update the PPP policy framework to address healthcare projects specifically. This should include details about their financing, services pricing, social imperatives, annual unitary payments, concession terms, etc.

High-end tests or therapies (MRI, PET CT, radiation therapy, etc) and specialty procedures (cardiac surgery, vascular surgery, neurosurgery, etc) can also be referred from public hospitals to private ones, where a portion of the fees are subsidised and investments in costly set-ups are avoided.

During winter, a large portion of private hospitals' capacity remain idle. The government can take advantage of this usable capacity by deferring or scheduling non-emergency patients and procedures from public hospitals to these private facilities. Once again, a portion of the cost can be subsidised, making the services affordable for lower income patients. It also gives the government control over pricing and standards of services in private facilities. Outsourcing non-critical activities (laundry, dietary needs, etc) of large public hospitals to specialised private companies can also bring much needed efficiency and higher quality to existing services.

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Another way forward is to redesign existing PPP heath projects in the pipeline. Instead of rent seeking, we should focus on securing capacity for low-income patients. Thus, the private partner is also incentivised and does not need to worry about capacity utilisation. The government can also offer subsidised land in tier two cities (as health specialisations are now concentrated in the metros) to proven healthcare operators to build and manage hospitals. Again, it can continue to participate in the service mix by offering subsidies to low-income patients in order to ensure equitable access.

This can even be expanded by allowing healthcare operators to run primary/community health centres. The government can still appoint doctors/health professionals (nurse, medical assistant, etc) who will be stationed at the centres, thus boosting the quality of services and also generating employment for trained health professionals.

Finally, we should also tag national identity cards (NIDs) to individual clinical records (EMR), thus fostering referral from primary care to secondary/tertiary hospitals, and also, from public hospitals to private facilities for more complex or resource-intensive treatments. The NID system can help to identify the target population for subsidies, making sure the benefits reach the deserving ones.

Currently, 65 percent of healthcare is provided by the private sector in Bangladesh, but to ensure optimum level of care for all, a joint approach between the public and private sectors, utilising both of their strengths, is essential for developing an equitable and accessible healthcare sector in the country.

Dr A M Shamim is managing director at Labaid Group.